OAR Chapter 410 — Oregon Health Authority, Health Systems Division: Medical Assistance Programs

Division 1 PROCEDURAL RULES

Or. Admin. R. 410-001-0000 Model Rules of Procedure

The Oregon Health Authority (Authority), Health Systems Division (Division), chapter 410, shall adhere to Authority rules in chapter 943 regarding Model Rules of Procedure, Notices of Rulemaking, Adoption of Temporary Rules, and Delegation of Rulemaking Authority.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
DMAP 18-2018, amend filed 03/21/2018, effective 04/11/2018
OMAP 9-2006, f. 5-3-06, cert. ef. 6-1-06
HR 7-1991, f. & cert. ef. 1-25-91
HR 1-1988, f. & cert. ef. 1-4-88
HR 1-1986, f. & ef. 4-2-86
HR 6-1982, f. & ef. 7-1-82
HR 5-1980, f. & ef. 9-17-80
HR 2-1978, f. & ef. 3-3-78
HR 5, f. & ef. 3-10-77
HR 3(Temp), f. & ef. 12-29-76

Or. Admin. R. 410-001-0005 Notice of Proposed Rulemaking and Adoption of Temporary Rules

Oregon Health Authority (Authority), Division of Medical Assistance Programs, chapter 410, will comply with Authority rules in chapter 943 for Notices of Rulemaking and adoption of Temporary rules.

History

Statutory/Other Authority: ORS 183.335, 183.341 & 413.042
Statutes/Other Implemented: ORS 183.325, 183.330, 183.335, 183.341, 414.025 & 414.065
OMAP 9-2006, f. 5-3-06, cert. ef. 6-1-06
HR 5-1980, f. & ef. 9-17-80
HR 2-1978, f. & ef. 3-3-78
HR 5, f. & ef. 3-10-77
HR 3(Temp), f. & ef. 12-29-76

Or. Admin. R. 410-001-0020 Delegation of Rulemaking Authority

Oregon Health Authority (Authority), Division of Medical Assistance Programs, chapter 410, will comply with Authority rules in chapter 943 for Delegation of Rulemaking Authority.

History

Statutory/Other Authority: ORS 183.335, 183.341 & 413.042
Statutes/Other Implemented: ORS 183.325, 183.330, 183.335, 183.341, 414.025 & 414.065
OMAP 9-2006, f. 5-3-06, cert. ef. 6-1-06
HR 7, f. & ef. 9-1-77
HR 6(Temp), f. & ef. 7-1-77

Division 50 TAX RULES

Or. Admin. R. 410-050-0700 Definitions

The following definitions apply to OAR 410-050-0700 to 410-050-0870:

(1) “Assessment Rate” means assessment applied to assessment paying facility’s inpatient or outpatient net patient revenue.

(2) “Authority” means the Oregon Health Authority.

(3) "Bad Debt" means the current period charge for actual or expected uncollectible accounts resulting from the extension of credit on inpatient and outpatient hospital services. Bad debt charges shall be offset by any recoveries received on accounts receivable during that current period, subject to final assessment reporting and reconciliation processes required in these rules.

(4) "Charges for Inpatient Care" means gross inpatient charges generated from room, board, general nursing, and ancillary services provided to patients who are expected to remain in the hospital at least overnight and occupy a bed (as distinguished from categories of health care items or services identified in 42 CFR 433.56(a)(2)-(19) that are not charges for inpatient hospital services). Charges for inpatient care include all payers, and are not limited to Medicaid patients.

(5) "Charges for Outpatient Care" means gross outpatient charges generated from services provided by the hospital to a patient who is not confined overnight. These services include all ancillary and clinic facility charges (as distinguished from categories of health care items or services identified in 42 CFR 433.56(a)(1) and (3)-(19) that are not charges for outpatient hospital services). Charges of outpatient care include all payers and are not limited to Medicaid charges.

(6) "Charity Care" means costs for providing inpatient or outpatient care services free of charge or at a reduced charge because of the indigence or lack of health insurance of the patient receiving the care services. Charity care results from a hospital's policy as reflected in its official financial statements to provide inpatient or outpatient hospital care services free of charge or at a reduced charge to individuals who meet financial criteria. Charity care does not include any amounts above the payments by the Authority that constitute payment in full under ORS 414.065(3), or above the payment rate established by contract with a prepaid managed care health services organization or health insurance entity for inpatient or outpatient care provided pursuant to such contract, or above the payment rate established under ORS 414.743 for inpatient or outpatient care reimbursed under that statute.

(7) "Contractual Adjustments" means the difference between the amounts charged based on the hospital's full, established charges and the amount received or due from the payer.

(8) "Declared Fiscal Year" means the fiscal year declared to the Internal Revenue Service (IRS).

(9) "Deficiency" means the amount by which the assessment, as correctly computed, exceeds the assessment, if any, reported and paid by the hospital. If, after the original deficiency is assessed, subsequent information shows the correct amount of assessment to be greater than previously determined, an additional deficiency arises.

(10) "Delinquency" means the hospital fails to file a report when due as required under these rules or fails to pay the assessment as correctly computed when the assessment was due.

(11) "Director" means the Director of the Authority.

(12) “Effective Rate” means the assessment collected by all assessment paying facilities divided by net patient revenue of all facilities within the class of services defined in 42 CFR 433.56.

(13) "Hospital" means a hospital licensed under ORS chapter 441. Hospital, as used in this section, does not include special inpatient care facilities as that term is defined in ORS 442.015, hospitals that provide only psychiatric care, pediatric specialty hospitals providing care to children at no charge, and public hospitals other than hospitals created by health districts under ORS 440.315 to 440.410. For purposes of these rules, the hospital shall be identified by using the federal payer identification number for the hospital.

(14) “Long Term Acute Care Hospital” means a hospital that is limited in services to only providing long term physical rehabilitation treatments.

(15) "Net Revenue" means the total amount of charges for inpatient or outpatient care provided by the hospital to patients, less charity care, bad debts, and contractual adjustments. Net revenue does not include revenue derived from sources other than inpatient or outpatient operations including but not limited to interest and guest meals and any revenue that is taken into account in computing a long-term care assessment under the long-term facility assessment.

(16) “Public Academic Medical Center” means a hospital that is formed as a public corporation pursuant to ORS 353.020 and is affiliated with a university for the purpose of medical education.

(17) “Specialty Psychiatry Hospital” means a hospital that is limited in services to only providing treatments for psychiatric or behavioral health conditions.

(18) “Type A Hospital” means a small remote hospital that has 50 or fewer beds and is more than 30 miles from another acute inpatient care facility.

(19) “Type B Hospital” means a small and rural hospital that has 50 or fewer beds and is 30 miles or less from another acute inpatient care facility.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: HB 2010 (2025)
DMAP 69-2025, amend filed 09/23/2025, effective 09/26/2025
DMAP 64-2017, amend filed 12/29/2017, effective 01/01/2018
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 33-2009, f. & cert. ef. 10-1-09
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0710 General Administration

(1) The purpose of these rules is to implement the assessment imposed on hospitals in Oregon.

(2) The Authority shall administer, enforce, and collect the hospital assessment. The Authority may assign employees, auditors, and other agents as designated by the Director to assist in the administration, enforcement, and collection of the assessments.

(3) The Authority may adopt forms and reporting requirements, and change the forms and reporting requirements, as necessary, to administer, enforce, and collect the assessments.

(4) The Authority may not use moneys from the Hospital Quality Assurance Fund to supplant, directly or indirectly, other moneys made available to fund services described in Section 9, Chapter 736, Oregon Laws 2003 as amended by Section 2, Chapter 757, Oregon Laws 2005.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0720 Disclosure of Information

(1) Except as otherwise provided by law, the Authority may not publicly divulge or disclose the amount of income, expense, or other particulars set forth or disclosed in any report or return required in the administration of the assessments. Particulars include but are not limited to social security numbers, employer numbers, or other hospital identification numbers, and any business records required to be submitted to or inspected by the Authority or its designee to allow it to determine the amounts of any assessments, delinquencies, deficiencies, penalties, or interest payable or paid, or otherwise administer, enforce, or collect a health care assessment to the extent that such information shall be exempt from disclosure under ORS 192.501(5) or other basis for exemption under Oregon's public records law.

(2) The Authority may:

(a) Furnish any hospital, or its authorized representative, upon request of the hospital or representative, with a copy of the hospital's report filed with the Authority for any quarter, or with a copy of any report filed by the hospital in connection with the report, or with a copy of any other information the Authority considers necessary;

(b) Publish information or statistics so classified as to prevent the identification of income or any particulars contained in any report or return;

(c) Disclose and give access to an officer or employee of the Authority or its designee, or to the authorized representatives of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, the Controller General of the United States, the Oregon Secretary of State, the Oregon Department of Justice, the Oregon Department of Justice Medicaid Fraud Control Unit, and other employees of the state or federal government to the extent the Authority deems disclosure or access necessary or appropriate for the performance of official duties in the Authority's administration, enforcement, or collection of the assessments.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0730 Entities Subject to the Hospital Assessment

Each hospital in Oregon is subject to the hospital assessment except:

(1) Hospitals operated by the United States Department of Veterans Affairs;

(2) Public academic medical centers;

(3) Specialty Psychiatric Hospitals;

(4) Long Term Acute Care Hospitals.

History

Statutory/Other Authority: ORS 413.042, 410.070 & 411.060
Statutes/Other Implemented: HB 2010 (2025)
DMAP 69-2025, amend filed 09/23/2025, effective 09/26/2025
DMAP 64-2017, amend filed 12/29/2017, effective 01/01/2018
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0740 The Hospital Assessment: Calculation, Report, Due Date

(1) The amount of the assessment equals the assessment rate multiplied by the hospital’s net revenue, consistent with OAR 410-050-0750, 410-050-0860, and 410-050-0861. The assessment shall be imposed on net revenues earned by the hospital on or after January 1, 2004, based on calendar quarters. The first calendar quarter begins on January 1; the second calendar quarter begins on April 1; the third calendar quarter begins on July 1; and the fourth calendar quarter begins on October 1.

(2) The assessment rate shall be determined in accordance with OAR 410-050-0860 and 410-050-0861.

(3) The hospital shall file the quarterly report on a form approved by the Authority on or before the 45th day following the end of the calendar quarter for which an assessment is due. The quarterly payment is due and shall be paid at the same time required for filing the quarterly report. The hospital shall provide all information required on the quarterly report when due. Failure to file or pay when due shall be a delinquency.

(4) The fiscal year reconciliation report, including the financial statement and reconciliation statement, is due and shall be submitted to the Authority no later than the final day of the sixth calendar month after the hospital's declared fiscal year end. The fiscal year reconciliation assessment payment is due and shall be paid at the same time required for filing the fiscal year reconciliation report. The hospital shall provide all information required on the fiscal year reconciliation report when due. Failure to file or pay when due shall be a delinquency.

(5) Any report, statement, or other document required to be filed under any provision of these rules must be certified by the hospital’s chief financial officer or designee. The certification shall attest, based on best knowledge, information, and belief, to the accuracy, completeness, and truthfulness of the document.

(6) Payments may be made electronically or by paper check. If the hospital pays electronically, the accompanying report may either be faxed to the Authority at the fax number provided on the report form or mailed to the address provided on the report form. If the hospital pays by paper check, the accompanying report shall be mailed with the check to the address provided on the report form.

(7) The Authority may charge the hospital a fee of $100 if, for any reason, the check, draft, order, or electronic funds transfer request is dishonored. This charge is in addition to any penalty for nonpayment of the assessment that may also be due.

History

Statutory/Other Authority: 413.042, 410.070 & 411.060
Statutes/Other Implemented: 2017 HB 2391
DMAP 64-2017, amend filed 12/29/2017, effective 01/01/2018
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0750 Reporting Total Net Revenue, Use of Estimated Revenue for Quarterly Reports

(1) A hospital shall submit quarterly reports and quarterly payments for the calendar quarters for which an assessment is due consistent with sections (2) and (5) of this rule, and shall submit a fiscal year reconciliation report that includes a reconciliation statement, audited financial statement, and any fiscal year reconciliation assessment payment based on the hospital's declared fiscal year end consistent with sections (3) and (5) of this rule.

(2) The quarterly reports and quarterly assessment payments shall be based on estimated net revenue, which shall be referred to as estimated assessment. Estimated assessment is the amount of assessment the hospital expects to owe for the current calendar quarter. The hospital shall calculate the estimated assessment based on net revenues using the hospital's interim financial results for the quarter for which the assessment is due. An estimated quarterly report is due for each calendar quarter for which an assessment is due, based on the rate of assessment applicable to that quarter. The quarterly payment is due and shall be paid at the same time required for filing the quarterly report.

(3) The fiscal year reconciliation report and fiscal year reconciliation assessment payment shall be based on the amount of assessment the hospital actually owes based on annual net revenue for all calendar quarters for which an estimated assessment payment is due during the hospital's declared fiscal year. The hospital shall calculate the annual net revenue for the hospital's declared fiscal year. The fiscal year reconciliation assessment payment due shall be the calculated assessment (using the assessment rate applicable to the appropriate quarter, described in subsection (c) below for fiscal year reconciliation assessment calculation purposes) on the annual net revenue reduced by the estimated assessment payments made for each assessment quarter of the hospital's declared fiscal year. The hospital shall provide all information required in the fiscal year reconciliation report when due, even if no fiscal year reconciliation assessment payment is owed:

(a) When the fiscal year reconciliation report is submitted, it shall be accompanied by the hospital's declared fiscal year end audited financial statement for the declared fiscal year on which the fiscal year reconciliation report and fiscal year reconciliation assessment payments are based;

(b) The fiscal year reconciliation report shall include a reconciliation statement describing the relationship between the audited financial statement and annual net revenues subject to the assessment. The reconciliation statement may be descriptive in form and shall be consistent with the accounting principles used in the audited financial statement;

(A) If all assessment quarters were subject to the same rate established in OAR 410-050-0160 and 410-050-0861, then the rate applicable to the final reconciliation is the assessment rate applicable to all such quarters. For example, if the hospital's declared fiscal year is July 1, 2004 to June 30, 2005, then the assessment rate is .93 percent of annual net revenue;

(B) If different assessment rates apply to calendar quarters in the hospital's declared fiscal year, the hospital shall apply a blended rate to the total annual net revenue to determine the fiscal year reconciliation assessment due. A blended rate is the average of the rates applicable to all assessment quarters. The Authority shall notify the hospital of the amount of the applicable blended rate. For example, if the hospital's declared fiscal year overlaps two quarters assessed at a rate of .93 percent and two quarters assessed at .50 percent, then the blended rate for purposes of the annual reconciliation is .715 percent. For purposes of calculating the fiscal year reconciliation assessment due, the hospital shall multiply the annual net revenue by the blended rate.

(d) If the total estimated assessment payments already paid by the hospital for the declared fiscal year exceed the amount of the fiscal year reconciliation assessment actually due, the fiscal year reconciliation report shall identify the difference and the hospital shall adjust the fiscal year reconciliation assessment due amount in the fiscal year reconciliation report for that assessment year;

(e) The fiscal year reconciliation report, audited financial statement, and reconciliation statement shall be due and submitted to the Authority no later than the final day of the sixth calendar month after the hospital's declared fiscal year end. The fiscal year reconciliation assessment payment (if owed) is due and shall be paid at the same time required for filing the fiscal year reconciliation report. Failure to file or pay when due shall be a delinquency;

(f) If the declared fiscal year end audited financial statement for the hospital is not available within the time required in subsection (e), a fiscal year reconciliation assessment payment (if owed) and fiscal year reconciliation report must be submitted within the time period specified under subsection (e). The hospital may use interim financial statements to determine the amount of the fiscal year reconciliation assessment due and may submit a justification statement with the fiscal year reconciliation report due no later than the date specified in subsection (e) signed by the hospital’s chief financial officer informing the Authority when the audited financial statement is due and certifying that an amended fiscal year reconciliation report, including the reconciliation statement, shall be provided to the Authority within 30 days of the hospital's receipt of the audited financial statement. Reports and payments made after the time period required in subsection (e) shall be submitted in compliance with OAR 401-050-0760;

(g) If the hospital does not receive audited financial statements, then internal financial statements signed by the hospital's chief financial officer shall be submitted where these rules otherwise require audited financial statements;

(h) If the effective date of the assessment is not at the start of the hospital's declared fiscal year, then the annual net revenue for the first fiscal year reconciliation report shall be calculated based on the number of quarters subject to the assessment versus the total number of quarters in the hospital's declared fiscal year. For example, if the assessment is effective on July 1, 2004 for a hospital with a declared fiscal year ending December 31, 2004, the annual net revenues shall be calculated as follows: total net revenues for the declared fiscal year divided by two (two of four quarters subject to the assessment).

(4) The Authority may not find a payment deficiency for estimated quarterly assessments as long as the hospital paid the estimated assessments and submitted the quarterly report no later than the quarterly due date and the estimated assessment amount was not less than the equivalent of the assessment payment that would have been determined based on the hospital's annual net revenue for its most recent prior declared fiscal year divided by four and multiplied times the assessment rate for the quarter in which the actual estimated assessment is due. Annual net revenue for purposes of section (4) of this rule means the twelve month period in which the hospital's most recent prior declared fiscal year occurred, regardless of whether the prior quarters were subject to an assessment. For example, if the annual net revenue for the most recent prior declared fiscal year was $4 million; divide that total by 4 ($1 million) and multiply the product times the current assessment rate for the assessment quarter (.93 percent). In this example, the estimated quarterly assessment payment may not be less than $9,300 in order to receive the benefit of section (4) of this rule:

(a) If the hospital seeks to use the process in section (4) of this rule, no later than the date on which the first quarterly estimated assessment and report is due (for example, December 13, 2004, for the first assessment quarter), the hospital shall provide the Authority with a copy of the hospital's audited financial statement for the hospital's most recent prior declared fiscal year and identify the hospital's annual net revenue amount for that declared fiscal year, regardless of whether any assessments were due for that year;

(b) If the hospital does not receive audited financial statements, then internal financial statements from the hospital's most recent prior declared fiscal year signed by the chief financial officer may be used for this purpose.

(5) All of the due dates for filing reports or paying assessments are established in OAR 410-050-0740, unless the Authority permits a later payment date. If a hospital requests an extension, the Authority, in its sole discretion, shall determine whether to grant an extension. There shall be a delinquency for each quarter the hospital fails to pay the estimated assessment or file the quarterly report when due. There shall be a delinquency if the hospital fails to pay the fiscal year reconciliation assessment or file the fiscal year reconciliation report, including financial statements and reconciliation statement, when due.

(6) A hospital shall declare the date of the hospital's declared fiscal year end for purposes of establishing final assessment reporting requirements under this rule. The declaration shall be filed with the Authority no later than December 13, 2004, or the first date that an estimated quarterly report and assessment is due. The hospital shall notify the Authority within 30 days of a change to the hospital's declared fiscal year end. A change in declared fiscal year end shall be applied to the hospital's next future declared fiscal year for purposes of calculating the final assessment and filing the final report.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 29-2008, f. 8-29-08, cert. ef. 9-1-08
DMAP 13-2008(Temp), f. & cert. ef. 6-12-08 thru 12-8-08
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0760 Filing an Amended Report

(1) A hospital that submits a fiscal year reconciliation report without an audited financial statement shall submit an amended fiscal year reconciliation report, an audited financial statement, and such additional fiscal year reconciliation payment (if owed) for assessments and deficiencies. The information shall be submitted within 180 days after the fiscal year reconciliation report due date.

(2) Claim for Refund:

(a) If the amount of the assessment in the amended fiscal year reconciliation report is less than the amount paid by the hospital, the Authority may refund the overpayment. A refund may not exceed the assessment amount actually paid by the hospital;

(b) The hospital shall provide all information required on the report. No refunds shall be made prior to the Authority receiving the hospital's audited financial statement for the declared fiscal year. The Authority may audit the hospital, request additional information, or request an informal conference prior to granting a refund or as part of its review;

(c) If there is an amount due from the hospital to the Authority for any past due assessments or penalties, any refund otherwise allowable shall first be applied to the unpaid assessments and penalties, and the hospital notified;

(d) A hospital may not deduct from current, prospective, or future assessment payments an amount to which it claims to be entitled as a refund for a prior period. The claim for refund shall be made to the Authority. .

(3) Payment of Delinquency:

(a) If the amount of the annual assessment imposed is more than the amount paid by the hospital, the hospital shall file an amended fiscal year reconciliation report and pay the additional fiscal year reconciliation assessment and deficiency. The penalty under OAR 410-050-0800 shall stop accruing after the Authority receives the amended fiscal year reconciliation report, the annual audited financial statement, and payment of the total fiscal year reconciliation assessment and deficiency for year; except to the extent provided in OAR 410-050-0750(4)(a);

(b) No refunds shall be made prior to the Authority receiving the hospital audited financial statement for the declared fiscal year. The Authority may audit the hospital, request additional information, or request an informal conference prior to granting a refund or as part of its review;

(c) If there is an error in the determination of the assessment due, the hospital may describe the circumstances of the late additional payment with the filing of the amended report. The Authority, in its sole discretion, may determine that the late additional payment does not constitute a failure to file a report or pay an assessment giving rise to the imposition of a penalty. In making this determination, the Authority shall consider the circumstances, including but not limited to: nature and extent of the error; hospital explanation of the circumstances related to the error; evidence of prior errors; and evidence of prior penalties (including evidence of informal dispositions or settlement agreements). This provision only applies if the hospital has filed a timely original report and paid the assessment identified in the report.

(4) If the Authority discovers or identifies information in the administration of these assessment rules that it determines could give rise to the issuance of a notice of proposed action, the Authority shall issue notification pursuant to OAR 410-050-0810.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0770 Determining the Date Filed

(1) For the purposes of these rules, any reports, requests, appeals, payments, or other response by the hospital shall be received by the Authority either:

(a) Before the close of business on the date due; or

(b) If mailed, postmarked before midnight of the due date.

(2) When the due date falls on a Saturday, Sunday, or a legal holiday, the date filed is on the next business day following the Saturday, Sunday, or legal holiday.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0780 Records Audit by the Authority

(1) The hospital shall maintain financial records necessary and adequate to determine the net revenue for any calendar period for which an assessment may be due.

(2) The Authority or its designee may audit the hospital's records at any time for a period of five years following the date the assessment is due to verify or determine the hospital's net revenue.

(3) The Authority may issue a notice of deficiency or issue a refund based upon its audit findings.

(4) Any audit, finding, or position may be reopened if there is evidence of fraud, malfeasance, concealment, misrepresentation of material fact, omission of income, or collusion either by the hospital or by the hospital and a representative of the Authority.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0790 Determining Assessment for Hospital Failure to File

(1) The law places an affirmative duty on the hospital to file a timely and correct report.

(2) In the case of a failure by the hospital to file a report or to maintain necessary and adequate records, the Authority shall determine the hospital’s assessment liability according to the best of its information and belief. Best of its information and belief means the Authority shall use evidence available to the Authority at the time of the determination on which a reasonable person would rely on in determining the assessment. The Authority's determination of assessment liability shall be the basis for the assessment due in any notice of proposed action.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0800 Financial Penalty for Failure to File a Report or Failure to Pay Tax When Due

(1) A hospital that fails to file a quarterly report or pay a quarterly assessment when due shall be subject to a penalty of up to $500 per day of delinquency. The Authority, in its sole discretion, shall determine the penalty for failure to pay the assessment or file a report. In making this determination, the Authority shall consider evidence such as prior late payments, prior penalties, and circumstances related to delinquency. The penalty accrues from the date of delinquency, notwithstanding the date of any notice under these rules.

(2) A hospital that fails to file a fiscal year reconciliation report when due is subject to a penalty of up to $500 per day of delinquency. The Authority, in its sole discretion, shall determine the penalty for failure to pay the assessment or file a report. In making this determination, the Authority shall consider evidence such as prior late payments, prior penalties, and circumstances related to delinquency. The penalty accrues from the date of delinquency, notwithstanding the date of any notice under these rules.

(3) A hospital that files a fiscal year reconciliation report, but fails to pay a fiscal year reconciliation assessment when due is subject to a penalty of up to $500 per day of delinquency up to a maximum of five percent of the amount due. The Authority, in its sole discretion, shall determine the penalty for failure to pay the reconciliation assessment payment or file a fiscal year reconciliation report. In making this determination, the Authority shall consider evidence such as prior late payments, prior penalties, and circumstances related to delinquency. The penalty accrues from the date of delinquency, notwithstanding the date of any notice under these rules.

(4) The total amount of penalty imposed under this section for each reporting period may not exceed five percent of the assessment for the reporting period for which penalty is being imposed.

(5) The Authority shall collect any penalties imposed under this section and deposit the funds in the Authority's account established under ORS 413.101.

(6) Penalties paid under this section are in addition to the hospital's assessment liability.

(7) If the Authority determines that a hospital is subject to a penalty, the Authority shall issue a notice of proposed action as described in OAR 410-050-0810.

(8) If a hospital requests a contested case hearing pursuant to OAR 410-050-0830, the Director, at the Director's sole discretion, may waive or reduce the amount of penalty assessed.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 33-2009, f. & cert. ef. 10-1-09
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0810 Notice of Proposed Action

(1) Prior to issuing a notice of proposed action, the Authority shall notify the hospital of the potential deficiency or failure to report that could give rise to the imposition of a penalty. The Authority shall issue a notification letter within 30 calendar days of the report or payment due date. The hospital shall have 30 calendar days from the date of the notice to respond. The Authority may consider the response and any amended final report under OAR 410-050-0760 in its notice of proposed action. In all cases that the Authority has determined that a hospital has an assessment deficiency or failure to report, the Authority shall issue a notice of proposed action. The Authority may not issue a notice of proposed action if the issue is resolved satisfactorily within 59 days from the date of mailing the notification letter.

(2) The Authority shall issue a notice of proposed action within 60 calendar days from the date of mailing the notification letter.

(3) Contents of the notice of proposed action shall include:

(a) The applicable reporting period;

(b) The basis for determining the corrected amount of assessment;

(d) The amount of assessment paid by the hospital;

(e) The resulting deficiency, which is the difference between the amount received by the Authority and the corrected amount due as determined by the Authority;

(f) Statutory basis for the penalty;

(g) Amount of penalty per day of delinquency;

(h) Date upon which the penalty began to accrue;

(i) Date the penalty stopped accruing or circumstances under which the penalty shall stop accruing;

(j) The total penalty accrued up to the date of the notice;

(k) Instructions for responding to the notice; and

(l) A statement of the hospital's right to a hearing.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 29-2008, f. 8-29-08, cert. ef. 9-1-08
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0820 Required Notice

(1) The Authority shall send any required notice to the address and contact person identified by the hospital on its most recently filed report.

(2) Any notice required to be sent to the Authority shall be sent to the point of contact identified on the communication from the Authority to the hospital.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0830 Hearing Process

(1) Any hospital that receives a notice of proposed action may request a contested case hearing under ORS 183.

(2) The hospital may request a hearing by submitting a written request within 20 days of the date of the notice of proposed action.

(3) Prior to the hearing, the hospital shall meet with the Authority for an informal conference:

(a) The informal conference may be used to negotiate a written settlement agreement.

(b) If the settlement agreement includes a reduction or waiver of penalties, the agreement shall be approved and signed by the Director.

(4) Except as provided in section (5) of this rule, if the case proceeds to a hearing, the administrative law judge shall issue a proposed order. The Authority shall issue a final order.

(5) Nothing in this section shall preclude the Authority and the hospital from agreeing to informal disposition of the contested case at any time, consistent with ORS 183.415(5).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0840 Final Order of Payment

A final order of payment is a final Authority action, expressed in writing, based on a notice of proposed action where a payment amount is due to the Authority. The Authority shall issue a final order of payment for deficiencies or penalties when:

(1) The hospital did not make a timely request for a hearing;

(2) Any part of the deficiency and penalty was upheld after a hearing; or

(3) Upon the agreement of the hospital and the Authority.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0850 Remedies Available after Final Order of Payment

Any amounts due and owing under the final order of payment and any interest thereon may be recovered by Oregon as a debt to the state, using any available legal and equitable remedies. These remedies include, but are not limited to:

(1) Collection activities including, but not limited to, deducting the amount of the final deficiency or penalty from any sum then or later owed to the hospital by the Authority; and

(2) Every payment obligation owed by the hospital to the Authority under a final order of payment shall bear interest at the statutory rate of interest in ORS 82.010 accruing from the date of the final order of payment and continuing until the payment obligation, including interest, has been discharged.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 2015 HB 2395
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0860 Director Determines Assessment Rate

(1) The Director shall determine the inpatient and outpatient assessment rate separately.

(2) The rate of assessment shall be imposed on the net revenue of each hospital subject to the assessment. The Director shall consult with representatives of hospitals before setting the rate.

(3) The Director may reduce the inpatient or outpatient rate of assessment to the maximum rate allowed under federal law if the reduction shall set the assessment rate to an effective date that results in compliance with the maximum safe harbor rate required to comply with federal law. If the rate is changed pursuant to this section, the Director shall notify the hospitals as to the effective date of the rate change.

(4) The Director may impose a different inpatient and outpatient assessment rate on Type A hospitals and Type B hospitals to take into account the hospital’s financial position.

(5) A hospital is not guaranteed that any additional moneys paid to the hospital in the form of payments for services will equal or exceed the amount of the assessment paid by the hospital.

(6) If the Director adjusts the rates, such changes shall be retroactively effective to the beginning of the calendar year quarter the adjustment occurs in.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: HB 2010 (2025)
DMAP 69-2025, amend filed 09/23/2025, effective 09/26/2025
DMAP 64-2017, amend filed 12/29/2017, effective 01/01/2018
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 34-2005, f. 7-8-05, cert. ef. 7-11-05
OMAP 28-2005(Temp), f. & cert. ef. 5-10-05 thru 11-5-05
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 91-2004(Temp), f. & cert. ef. 12-3-04 thru 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Or. Admin. R. 410-050-0861 Assessment Rate

(1) DRG Hospital Assessment rate.

(a) The assessment rate for the period beginning January 1, 2005, and ending June 30, 2006, is .68 percent.

(b) The assessment rate for the period beginning July 1, 2006, and ending December 31, 2007, is .82 percent.

(d) The assessment rate for the period of January 1, 2008 through June 30, 2009 does not apply to the period beginning July 1, 2009.

(e) The assessment rate for the period beginning July 1, 2009, and ending September 30, 2009, is .15 percent.

(f) The assessment rate for the period beginning October 1, 2009, and ending June 30, 2010, is 2.8 percent.

(g) The assessment rate for the period beginning July 1, 2010, and ending June 30, 2011, is 2.32 percent.

(h) The assessment rate for the period beginning July 1, 2011, and ending September 30, 2011, is 5.25 percent.

(i) The assessment rate for the period beginning October 1, 2011, and ending December 31, 2011, is 5.08 percent.

(j) The assessment rate for the period beginning January 1, 2012, and ending March 31, 2013, is 4.32 percent.

(k) The assessment rate for the period beginning April 1, 2013, and ending September 30, 2014, is 5.30 percent.

(l) The assessment rate for the period beginning October 1, 2014, and ending March 31, 2016, is 5.80 percent.

(m) The assessment rate for the period beginning April 1, 2016, and ending June 30, 2017, is 5.30 percent.

(n) The assessment rate for the period beginning July 1, 2017, and ending October 4, 2017, is 6.00 percent.

(o) The assessment rate for the period beginning October 5, 2017, and ending December 31, 2017, is 5.30 percent.

(p) The assessment rate for the period beginning January 1, 2018, is 6.0 percent.

(q) The assessment rate for period beginning July 1, 2025, and ending September 30, 2025, is 10.54 percent for outpatient and 7.73 percent for inpatient.

(r) The assessment rate for period beginning October 1, 2025, and ending December 31, 2025 is 9.80 percent for outpatient and 8.64 percent for inpatient.

(s) The assessment rate for period beginning January 1, 2026, and ending March 31, 2026 is 8.30 percent for outpatient and 7.47 percent for inpatient.

(t) The assessment rate for period beginning April 1, 2026, and ending June 30, 2026 is 8.08 percent for outpatient and 7.30 percent for inpatient.

(u) The assessment rate for period beginning July 1, 2026, 8.08 percent for outpatient and 7.30 percent for inpatient.

(2) Type A/B Assessment rate.

(a) For Type A/B hospitals, the assessment rate for the period beginning January 1, 2018, and ending June 30, 2018, is 4.00 percent.

(b) For Type A/B hospitals, the assessment rate for the period beginning July 1, 2018, and ending June 30, 2019, is 4.75 percent.

(c) For Type A/B hospitals, the assessment rate for the period beginning July 1, 2019, and ending November 30, 2019 is 4.20 percent.

(d) For Type A/B hospitals, the assessment rate for the period beginning December 1, 2019, and ending December 31, 2019 is 2.69 percent.

(e) For Type A/B hospitals, the assessment rate for the period beginning January 1, 2020, and ending September 30, 2020 is 5.5 percent.

(f) For Type A/B hospitals, the assessment rate for the period beginning October 1, 2020, is 6.00 percent.

History

Statutory/Other Authority: ORS 413.042, 410.070 & 411.060
Statutes/Other Implemented: HB 2010 (2025)
DMAP 35-2026, amend filed 08/20/2026, effective 08/20/2026
DMAP 21-2026, amend filed 06/04/2026, effective 06/04/2026
DMAP 10-2026, temporary amend filed 03/24/2026, effective 03/24/2026 through 06/27/2026
DMAP 102-2025, temporary amend filed 12/30/2025, effective 12/31/2025 through 06/27/2026
DMAP 69-2025, amend filed 09/23/2025, effective 09/26/2025
DMAP 57-2025, temporary amend filed 06/30/2025, effective 07/01/2025 through 12/27/2025
DMAP 12-2021, amend filed 03/25/2021, effective 03/29/2021
DMAP 52-2020, temporary amend filed 09/28/2020, effective 10/01/2020 through 03/29/2021
DMAP 50-2019, amend filed 12/12/2019, effective 12/27/2019
DMAP 49-2019, temporary amend filed 11/25/2019, effective 12/01/2019 through 12/27/2019
DMAP 17-2019, temporary amend filed 06/14/2019, effective 07/01/2019 through 12/27/2019
DMAP 96-2018, amend filed 10/25/2018, effective 11/01/2018
DMAP 79-2018, temporary amend filed 06/27/2018, effective 07/01/2018 through 12/27/2018
DMAP 64-2017, amend filed 12/29/2017, effective 01/01/2018
DMAP 43-2017, temporary amend filed 10/05/2017, effective 10/05/2017 through 12/27/2017
DMAP 26-2017(Temp), f. 6-30-17, cert. ef. 7-1-17 thru 12-27-17
DMAP 51-2016, f. 8-9-16, cert. ef. 9-1-16
DMAP 15-2016(Temp), f. 3-31-16, cert. ef. 4-1-16 thru 9-27-16
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 68-2014, f. & cert. ef. 12-1-14
DMAP 58-2014(Temp), f. & cert. ef. 10-1-14 thru 3-29-15
DMAP 41-2013, f. & cert. ef. 8-1-13
DMAP 15-2013(Temp), f. & cert. ef. 4-1-13 thru 9-27-13
DMAP 8-2012, f. 2-27-12, cert. ef. 3-1-12
DMAP 50-2011(Temp), f. 12-30-11, cert. ef. 1-1-12 thru 4-30-12
DMAP 31-2011, f. 10-28-11, cert. ef. 11-1-11
DMAP 26- 2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 11-1-11
DMAP 16-2011(Temp), f. & cert. ef. 7-1-11 thru 11-1-11
DMAP 21-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 33-2009, f. & cert. ef. 10-1-09
DMAP 27-2009, f. & cert. ef. 9-1-09
DMAP 25-2009(Temp), f. & cert. ef. 7-15-09 thru 1-10-10
DMAP 24-2009, f. & cert. ef. 7-1-09
DMAP 3-2008, f. & cert. ef. 1-25-08
DMAP 29-2007, f. 12-31-07, cert. ef. 1-1-08
OMAP 14-2006, f. 6-1-06, cert. ef. 7-1-06
OMAP 34-2005, f. 7-8-05, cert. ef. 7-11-05
OMAP 28-2005(Temp), f. & cert. ef. 5-10-05 thru 11-5-05

Or. Admin. R. 410-050-0870 Sunset Provisions

(1) The hospital assessment applies to net revenue received by hospitals on or after January 1, 2004, and before October 1, 2025.

(2) The Type A and B hospital assessment applies to net revenue received by hospitals on or after January 1, 2018, and before October 1, 2025.

(3) The hospital assessment applies to net revenue received by hospitals on or after September 1, 2025, and before October 1, 2032.

(4) The Type A and B hospital assessment applies to the net revenue received by hospitals on or after September 1, 2025 and before October 1, 2032.

History

Statutory/Other Authority: ORS 413.042, 410.070 & 411.060
Statutes/Other Implemented: HB 2010 (2025)
DMAP 69-2025, amend filed 09/23/2025, effective 09/26/2025
DMAP 35-2019, amend filed 08/27/2019, effective 10/01/2019
DMAP 64-2017, amend filed 12/29/2017, effective 01/01/2018
DMAP 52-2015, f. 9-22-15, cert. ef. 10-1-15
DAMP 17-2014, f. & cert. ef. 3-25-14
DMAP 53-2013(Temp), f. & cert. ef. 10-1-13 thru 3-29-14
DMAP 33-2009, f. & cert. ef. 10-1-09
DMAP 3-2008, f. & cert. ef. 1-25-08
OMAP 25-2005, f. 4-15-05, cert. ef. 5-7-05
OMAP 86-2004(Temp), f. & cert. ef. 11-9-04 thru 5-7-05

Division 110 SAFETY NET CAPACITY GRANT PROGRAM

Or. Admin. R. 410-110-0025 Scope

These rules establish criteria for awarding grants under the Safety Net Capacity Grant Program, which was established to ensure that safety net providers have capacity to serve vulnerable and underserved children in Oregon.

History

Statutory/Other Authority: ORS 413.225
Statutes/Other Implemented: ORS 413.225, 2015 c. 837 § 34 & 414.231
Renumbered from 409-110-0025, DMAP 65-2016, f. & cert. ef. 11-29-16
OHP 15-2016, f. & cert. ef. 11-1-16
OHP 8-2016(Temp), f. & cert. ef. 5-9-16 thru 11-4-16

Or. Admin. R. 410-110-0030 Definitions

The following definitions apply to OAR 409-110-0025 to 409-110-0045:

(1) “Authority” means the Oregon Health Authority.

(2) “Community-sponsored Clinic” means a non-profit, community-based clinic that does not receive state or federal funding and is sponsored by the local community in the form of grants and donations, including in-kind donations of goods and services.

(3) “Culturally and Linguistically Appropriate Services” means health care services that are respectful of and responsive to cultural and linguistic needs. Please refer to the “National Standards on Culturally and Linguistically Appropriate Services” (CLAS), United States Department of Health and Human Services, Office of Minority Health.

(4) “Primary Healthcare Service” means physical, oral, mental, behavioral, and vision health services that are delivered in a manner that reflects the state’s emphasis on patient-centered care.

(5) “Program” means the Safety Net Capacity Grant Program.

(6) “Safety Net Provider” means a public or non-profit federally qualified health center, school-based health center, tribal health clinic, rural health clinic, or community-sponsored clinic that provides primary care and preventive physical, oral, mental, behavioral and vision health services to low-income patients without charge or using a sliding scale.

(8) “Target Population” refers to children who are not eligible for the Oregon Healthy Kids Program for reasons other than income.

[ED.NOTE: Publications referenced are available from the agency]

History

Statutory/Other Authority: ORS 413.225
Statutes/Other Implemented: ORS 413.225, 2015 c. 837 § 34 & 414.231
Renumbered from 409-110-0030, DMAP 65-2016, f. & cert. ef. 11-29-16
OHP 15-2016, f. & cert. ef. 11-1-16
OHP 8-2016(Temp), f. & cert. ef. 5-9-16 thru 11-4-16

Or. Admin. R. 410-110-0035 Program Administration

(1) The Program is intended to ensure that the target population has access to primary physical, oral, mental, behavioral, and vision health services.

(2) The Authority shall award grants to safety net providers through the Program.

(3) Services covered through the Program are limited to primary and preventive physical, oral, mental, behavioral, and vision health services.

(4) Children in the target population through the age of 18 are eligible to receive services through the program.

(5) The grant amount awarded shall take into consideration the distribution and concentration of the target population in the proposed service area.

(6) The Program is competitive and proposals that include collaboration with community partners may be given preference.

(7) The Authority shall administer the Program including soliciting, reviewing, evaluating, and selecting successful grant proposals. The Authority shall also provide project monitoring, technical assistance and submit periodic status reports to interested parties.

(8) Grant funding shall be awarded for the remainder of the 2015-2017 biennium, with the possibility of extensions.

(10) The Authority shall distribute safety net grant funds to successful applicants on an incremental basis.

History

Statutory/Other Authority: ORS 413.225
Statutes/Other Implemented: ORS 413.225 & 2015 c. 837 § 34
Renumbered from 409-110-0035, DMAP 65-2016, f. & cert. ef. 11-29-16
OHP 15-2016, f. & cert. ef. 11-1-16
OHP 8-2016(Temp), f. & cert. ef. 5-9-16 thru 11-4-16

Or. Admin. R. 410-110-0040 Grant Award Process

(1) The Authority shall advertise grant proposals through publication on its website and through communication to eligible entities.

(2) All proposals must be submitted in a form specified by the Program and by the date specified in the solicitation document.

(3) The Authority shall document receipt of all proposals.

(4) To qualify for a grant through the Program, applicants must be able to credibly estimate the number of new and existing children in the target population they will serve, as well as the number of estimated visits for the target population.

(5) The Authority shall evaluate all proposals based upon but not limited to the following evaluation elements:

(a) Demonstrated capacity to provide primary health care services.

(b) Demonstrated capacity or description of a credible plan to serve the target population.

(c) Demonstrated capacity or description of a credible plan to assure that services are culturally and linguistically competent.

(d) Demonstrated capacity or description of a credible plan to identify, contact, and provide primary care services to the target population.

(e) Demonstrated readiness to be operational within 60 days of grant award.

(f) Maintenance of operating hours and locations to ensure accessibility.

(g) Demonstrated ability to partner with community-based and other community organizations and to leverage funds, where possible.

(h) Submission of a proposed work plan, including timeline, discrete programs and products, evaluation outcomes, and budget.

(i) Demonstrated capacity or description of a credible plan for implementing data systems that can report on delivery of services and health outcomes, preferably through the utilization of electronic health records that are Certification Commission for Health Information Technology certified.

(6) The Authority shall form a committee to consider and make recommendations on the submitted proposals.

(7) The Authority shall notify applicants, in writing, whether their proposal was selected for funding. The Authority shall provide a question and answer opportunity through electronic or telephone communication both before and after the selection of proposals.

History

Statutory/Other Authority: ORS 413.225
Statutes/Other Implemented: ORS 413.225, 2015 c. 837 § 34 & 414.231
Renumbered from 409-110-0040, DMAP 65-2016, f. & cert. ef. 11-29-16
OHP 15-2016, f. & cert. ef. 11-1-16
OHP 8-2016(Temp), f. & cert. ef. 5-9-16 thru 11-4-16

Or. Admin. R. 410-110-0045 Monitoring and Reporting Requirements

(1) A grantee shall:

(a) Submit grant reports to the Authority on a periodic basis. Grant reports will indicate progress to achieve grant benchmarks and goals and report on the expenditure of grant dollars. Failure to comply with reporting requirements may result in grant suspension or termination; and

(b) Report specific data or information, to be determined by the Authority.

(2) Grant disbursements are contingent on grantee achieving proposed service delivery levels. Failure to achieve proposed service levels or benchmarks may result in grant reduction or termination.

(3) Periodically grantee and the Authority shall jointly review progress.

History

Statutory/Other Authority: ORS 413.225
Statutes/Other Implemented: ORS 413.225, 2015 c. 837 § 34 & 414.231
Renumbered from 409-110-0045, DMAP 65-2016, f. & cert. ef. 11-29-16
OHP 15-2016, f. & cert. ef. 11-1-16
OHP 8-2016(Temp), f. & cert. ef. 5-9-16 thru 11-4-16

Division 115 OHP Bridge

Or. Admin. R. 410-115-0000 Purpose

The Purpose of this Chapter 410, Division 115, is to establish uniform standards for the Authority’s administration of Oregon Health Plan (OHP) Bridge (as defined in OAR 410-115-0005 below). The rules set forth below in this Chapter 410, Division 115 apply exclusively to the administration and provision of OHP Bridge. Any rule set forth in this Chapter 410, Division 115 that contradicts or conflicts with any rules of general applicability found in other Divisions included in OAR Chapter 410 are superseded by the rules and provisions in this OAR Chapter 410, Division 115.

History

Statutory/Other Authority: ORS 414.241 & 413.042
Statutes/Other Implemented: ORS 414.241, 413.042, 414.025, 414.65 & 414.706
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0005 Acronyms and Definitions

(1) The acronyms and definitions within this rule specifically pertain to OHP Bridge. This rule does not include an exhaustive list of acronyms and definitions that apply to OHP Bridge. Other acronyms and definitions that may apply to OHP Bridge are found in OAR 410-141-3500, OAR 410-120-0000, and OAR 410-200-0015.

(2) “Basic Health Program” means a joint federal and state funded program for medical assistance established under section 1331 of the federal Patient Protection and Affordable Care Act of 2010 and Title 42, Chapter IV, Subchapter 1 of the Code of Federal Regulations, which the state has elected to adopt and implement as OHP Bridge.

(3) “Oregon Health Plan (OHP) Bridge” means the health insurance programs established by the state under Oregon House Bill 4035 (2022 Regular Session) and in accordance with ORS 414.241 which is available to individuals who meet certain age, financial, and other eligibility requirements OAR Chapter 410, Division 200. OHP Bridge provides the same health insurance benefits (covered services) to all eligible individuals but due to federal law, OHP Bridge is delivered through two different medical assistance programs which are listed below in this rule:

(a) “OHP Bridge – Basic Medicaid” means the Medicaid eligibility category created by the state to provide OHP Bridge covered services to OHP Bridge – Basic Medicaid members described in OAR 410-200-0437.

(b) “OHP Bridge – Basic Health Program” means the Basic Health Program established by the state as a medical assistance program administered by the Authority, which provides OHP Bridge covered services to OHP Bridge – Basic Health Program members described in OAR 410-200-0438.

(4) “OHP Bridge Covered Services” means the services provided to OHP Bridge members.

(a) The OHP Bridge covered services for the OHP Bridge- Basic Health Program are described in OAR 410-115-0030 and in the OHP Bridge – Basic Health Program CCO Contract; and,

(b) The OHP Bridge covered services for recipients or members of OHP Bridge – Basic Medicaid are described in OAR 410-115-0030 and in the Medicaid CCO Contract.

(5). “OHP Bridge Members” means those individuals who are either:

(a) Enrolled in Coordinated Care Organizations after the Authority has processed their applications for medical assistance and determined they meet the financial and non-financial eligibility requirements for the OHP Bridge – Basic Health Program described in OAR 410-200-0438; or,

(b) Enrolled in OHP Bridge – Basic Medicaid after the Authority has processed their applications for medical assistance and determined they meet the financial and non-financial eligibility requirements described in OAR 410-200-0437.

(6) “OHP Bridge - BHP Trust Fund” means the Bridge Plan Fund established by ORS 414.245 to receive federal and non-federal funds that shall be used for the sole purpose of implementing and administering the OHP Bridge – Basic Health Program in compliance with Basic Health Program regulations found in 42 C.F.R. Part 600, Subpart H, and this OAR Chapter 410, Division 115.

(7) “OHP Bridge – Basic Health Program CCO Contract(s)” means an agreement between the State of Oregon acting by and through the Authority and a CCO to provide OHP Bridge – Basic Health Program covered services to OHP Bridge – Basic Health Program members.

(8) “Long-term Care” and “Long-term Services and Supports” has the same definition as in OAR 410-120-0000.

History

Statutory/Other Authority: ORS 413.071, 414.025, 414.241, 414.245 & 42 CFR 600.5
Statutes/Other Implemented: 414.025, 414.241, 414.245, ORS 413.042, 414.65 & 414.706
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0010 Application.

(1) The Authority shall conduct the application process for OHP Bridge in accordance with the provisions outlined in OAR 410-200-0110.

(2) Consistent with 42 C.F.R. 435.905(b), the Authority must provide assistance to all individuals who apply or want to apply for OHP Bridge (applicants), including without limitation, those applicants who may be of Limited English Proficiency, as well as individuals living with disabilities.

(3) Applicants to OHP Bridge may utilize authorized representatives in accordance with OAR 410-200-0111.

(4) Applicants to OHP Bridge have the right to receive application and health care system navigation assistance from assisters, navigators, and other individuals certified by the Authority to provide application assistance, in accordance with OAR 410-120-0045.

History

Statutory/Other Authority: ORS 411.400, 411.402, 411.404, 413.042, 414.241, 414.534 & 414.706
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 413.042, 414.241, 414.534, 414.706, 411.406, 411.439, 413.038, 414.025 & 414.536
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0015 Eligibility and Enrollment.

(1) Eligibility requirements for OHP Bridge – Basic Medicaid and OHP Bridge – Basic Health Program are described in OAR 410-200-0437 and in OAR 410-200-0438.

(2) Effective start dates for OHP Bridge – Basic Medicaid and OHP Bridge – Basic Health Program coverage are established in OAR 410-200-0115.

(3) In the event OHP Bridge coverage is incorrectly terminated or denied due to agency error, coverage shall commence or be reinstated as follows:

(a) If incorrectly denied due to agency error, the individual’s enrollment in OHP Bridge and their benefit coverage shall begin on the first day of the month in which benefits may have been effective had the Authority not erred in its initial determination; or

(b) If incorrectly terminated due to agency error, the individual’s OHP Bridge coverage shall be reinstated with no gap in coverage.

(4) OHP Bridge is not subject to any restricted application and enrollment period. Individuals have the right to apply to OHP Bridge at any time and, if determined eligible by the agency as set forth in this Division, be enrolled in OHP Bridge in accordance with this rule.

(5) Applicants who are determined to be ineligible for OHP Bridge have the right to appeal the determination in accordance with OAR Chapter 410, Division 141. If, on appeal, the applicant is determined to be eligible for OHP Bridge, eligibility shall be effective in accordance with section (3)(a) of this rule.

(6) Eligibility for OHP Bridge – Basic Health Program is evaluated for renewal every twelve (12) months.

(7) Eligibility for OHP Bridge – Basic Medicaid is evaluated for renewal as described in OAR 410-200-0115.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 414.241, 414.534, 42 CFR 433.138, 433.145-433.148, 435.3-435.4, 435.115-435.119, 435.170, 435.190, 435.222, 435.403, 435.940, 435.1200, 457.80, 457.340, 435.110, 458.350, 435.406-435.407, 435.952, 435.956, 435.1008, 457.320, 457.380, 435.608, 435.610, 435.916-435.917, 435.1205, 447.56, 457.350, 457.360, 457.805 & 600, 45 CFR 155.420 & 435.115
Statutes/Other Implemented: ORS 411.402, 411.404, 45 CFR 155.420, ORS 411.060, 411.095, 411.400, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.241, 414.440, 414.534, 414.536 & 414.706
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0020 Continuity of Health Care

The agency shall coordinate eligibility and enrollment between the Oregon Health Authority (Authority), the Department of Human Services (Department), and the Federally Facilitated Marketplace as set forth in OAR 410-200-0110 – Coordinated Eligibility and Enrollment Process with the Department of Human Services and the Federally Facilitated Marketplace.

History

Statutory/Other Authority: ORS 413.042, 414.241 & 42 CFR 600
Statutes/Other Implemented: ORS 413.042 & 414.241
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0025 Grievances and Appeals: Managed Care Entities Obligations; OHP Bridge Program Member Rights.

(1) In administering OHP Bridge, Managed Care Entities must comply with the grievance, appeal, and contested case administrative rules set forth in OARs 410-141-3875 through 410-141-3915.

(2) OHP Bridge members have the right to file a grievance, appeal an adverse benefit determination, and request a contested case hearing as described in OARs 410-141-3875 through OAR 410-141-3915.

History

Statutory/Other Authority: ORS 413.042, 414.065, 414.241 & 42 CFR 600.335
Statutes/Other Implemented: ORS 413.042, 414.065, 414.241, 414.727 & 42 CFR 600
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0030 OHP Bridge Covered Services.

(1) OHP Bridge members shall be eligible for the Oregon Health Plan (OHP) Bridge benefit package.

(a) Benefit Package identifier: BRG

(b) Coverage for the OHP Bridge benefit package includes:

(A) Coverage of the ten (10) essential health benefits described in section 1302(b) of the Affordable Care Act as adopted under 42 CFR 600.405;

(B) Covered Services set forth for the Oregon Health Plan and defined in OAR 410-141-3820; and,

(2) The OHP Bridge benefit package does not include:

(a) coverage for long-term care and long-term services and supports.

(b) coverage of Health Related Social Needs services defined in OAR 410-120-0000.

History

Statutory/Other Authority: ORS 413.042, 414.241 & 42 CFR 600
Statutes/Other Implemented: ORS 413.042, 414.241 & ORS 414.065
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0035 No Premiums or Copayments.

OHP Bridge members are not and shall not be required to pay any premiums, copayments and they do not and shall not have to pay any provider to receive covered services.

History

Statutory/Other Authority: ORS 413.042, 414.065, 414.241, 42 CFR 600.505, 600.510, 600.515, 600.520 & 600.525
Statutes/Other Implemented: ORS 413.042 & 414.241
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0040 Service Authorization.

The service authorization provisions for OHP Bridge are described in OAR 410-141-3835.

History

Statutory/Other Authority: ORS 413.042, 414.065, 414.241, 414.615, 414.625, 414.635, 414.651 & 42 CFR 600
Statutes/Other Implemented: ORS 413.042, 414.065, 414.241 & ORS 414.610-414.685
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0045 CCO Administration of OHP Bridge – Basic Health Program; OHP Bridge Enrollment and Choice of CCO.

(1) OHP Bridge – Basic Health Program shall be administered by Coordinated Care Organizations (CCOs) pursuant to an OHP Bridge – Basic Health Program CCO Contract entered into by each CCO and the state acting by and through the Authority.

(2) The terms and conditions included in the OHP Bridge – Basic Health Program CCO Contract shall comply with all applicable state and federal laws, including, without limitation 42 USC 18051, 42 CFR Part 660, ORS 414.241 and 414.245, and OAR Chapter 410, Division 141. The rules set forth in this Division 115, OAR Chapter 410, Division 141, and the federal regulations set forth in 42 CFR Part 600.

(3) Applicants determined by the Authority to be eligible for OHP Bridge – Basic Health Program shall be enrolled in a CCO. Enrollment and disenrollment from a CCO, including choice of CCO, shall be made in accordance with OAR 410-141-3805 and OAR 410-141-3810, except that:

(a) Exceptions to mandatory managed care enrollment described in OAR 410-141-3805 (4 – 16) do not apply to OHP Bridge - Basic Health Program; and

(b) OHP Bridge Basic Health Program members cannot be disenrolled from the OHP Bridge – Basic Health Program and be covered under the fee-for-service (FFS) delivery system under OAR 410-141-3810.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 414.241, 414.534, 42 CFR 600 & 600.300
Statutes/Other Implemented: ORS 411.402, 411.404, 414.241, 414.534, ORS 411.400, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 411.447, 414.536 & 414.706
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-115-0050 OHP Bridge - BHP Trust Fund.

The Authority shall maintain an OHP Bridge - BHP Trust Fund for the receipt of the federal funds and other non-federal funds the Authority is required to use to pay for the Basic Health Program. Pursuant to 42 CFR 600.705, the Authority does not have the right to use the funds maintained in the BHP Trust for any purpose other than the following:

(1) Paying contracted rates to the CCOs for providing OHP Bridge – Basic Health Program covered services to OHP Bridge – Basic Health Program members (including ancillary payments related to CCO or provider (or both) performance incentives, risk management, and similar purposes as set forth in the OHP Bridge – Basic Health Program CCO Contract);

(2) Paying the CCOs to provide additional covered services or benefits to OHP Bridge – Basic Health Program members, which may be delivered through a network managed by the Authority or its administrator;

(3) Paying health care providers directly for covered services that are not included in the OHP Bridge – Basic Health Program CCO contract(s), but are included in the BRG Benefit Package defined in OAR 410-115-0030; and,

(4) Paying health care providers directly to augment amounts paid by CCOs for services delivered to OHP Bridge – Basic Health Program members.

History

Statutory/Other Authority: ORS 413.042, 414.241, 414.245, 42 CFR 600, 600.700, 600.705, 600.710 & 600.715
Statutes/Other Implemented: ORS 413.042, 414.241, 414.245 & ORS 414.065
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Division 120 MEDICAL ASSISTANCE PROGRAMS

Or. Admin. R. 410-120-0000 Acronyms and Definitions

Identification of acronyms and definitions within this rule specifically pertain to their use within the Oregon Health Authority (Authority), chapter 410 administrative rules, applicable to medical assistance programs. This rule does not include an exhaustive list of program acronyms and definitions. For program and services definitions, see the appropriate OAR in the applicable division of chapter 410 administrative rules, and any appropriate governing acronyms and definitions in other Authority chapters such as 309 and 943 or the Oregon Department of Human Services (Department) administrative rules found in chapters 411, 413, or 461, or contact the Authority.

(1) “Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Authority or in reimbursement for services that are not medically necessary or medically appropriate. It also includes recipient practices that result in unnecessary cost to the Authority.

(2) “Action” means a termination, suspension of, or reduction in covered benefits, services, eligibility or an increase in beneficiary liability. This includes a determination by a skilled nursing facility or nursing facility to transfer or discharge a resident, or an adverse determination with regard to the preadmission screening and resident review requirements. For the definition as it is related to a Coordinated Care Organization (CCO) member, refer to OAR 410-141-3500.

(3) “Acupuncturist” means an individual licensed to practice acupuncture by the relevant state licensing board.

(4) “Acupuncture Services” means services provided by a licensed acupuncturist within the scope of practice as defined under state law.

(5) “Acute” means a condition, diagnosis, or illness with a sudden onset and that is of short duration.

(6) “Acquisition Cost” means, unless specified otherwise in individual program administrative rules, the net invoice price of the item, supply, or equipment plus any shipping or postage for the item.

(7) “Addictions and Mental Health Division” means the Division within the Authority’s Health Systems Division that administers mental health and addiction programs and services.

(8) “Adequate Record Keeping” means documentation that supports the level of service billed. See OAR 410-120-1360, Requirements for Financial, Clinical, and Other Records, and the individual provider rules.

(9) “Administrative Medical Examinations and Reports” means examinations, evaluations, and reports, including copies of medical records requested on the Oregon Health Plan (OHP) 729 form through the local Department branch office or requested or approved by the Authority to establish client eligibility for a medical assistance program or for casework planning.

(10) “Adults and Youths Discharged from an HRSN Eligible Behavioral Health Facility” means Members who have been discharged from one of the settings listed below within the last 365 calendar days. Eligibility for HRSN Services shall expire on the 366th calendar day after discharge.

(a) Acute Care Psychiatric Hospitals as defined in OAR 309-015-0005,

(b) Institution for Mental Diseases as defined in 42 CFR 435.1010,

(c) Integrated Psychiatric Residential Treatment Facilities and Residential Substance Use Disorders Treatment Programs as defined in OAR 309-022-0105,

(d) Residential Treatment Facilities (RTF) as defined in OAR 309-035-0105,

(e) Residential Treatment Homes (RTH) as defined in OAR 309-035-0105,

(f) Secure Residential Treatment Facilities (SRTF), as defined in OAR 309-035-0105,

(g) Psychiatric Residential Treatment Facilities (PRTF) as defined in OAR 309-022-0105, and

(h) Residential Substance Use Disorders Treatment Programs as defined in OAR 309-018-0105

(11) “Adults and Youths Released from Incarceration” means Members released from incarceration within the past 365 calendar days, including those released from state and federal prisons, local correctional facilities, juvenile detention facilities, Oregon Youth Authority closed custody corrections or tribal correctional facilities. Eligibility for HRSN Services shall expire on the 366th calendar day after release from a carceral facility.

(12) “Advance Directive” means an individual’s instructions to an appointed person specifying actions to take in the event that the individual is no longer able to make decisions due to illness or incapacity.

(13) “Adverse determination” means a determination made that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.

(14) “Adverse Event” means an undesirable and unintentional, though not necessarily unexpected, result of medical treatment.

(15) “Affiliation” means for provider requesting enrollment or revalidation as an Oregon Medicaid provider any of the following:

(a) Five (5) percent or greater direct or indirect ownership interest that an individual or entity has in another organization;

(b) A general or limited partnership interest (regardless of the percentage) that an individual or entity has in another organization;

(c) An interest in which an individual or entity exercises operational or managerial control over, or directly or indirectly conducts, the day-to-day operations of another organization, either under contract or through some other arrangement, regardless of whether or not the managing individual or entity is a W-2 employee of the organization; includes sole proprietorships;

(d) An interest in which an individual is acting as an officer or director of a corporation; or

(e) Any payment assignment relationship under 42 CFR 447.10(g).

(16) “Agent” means any person who has been delegated the authority to obligate or act on behalf of a provider.

(17) “Aging and People with Disabilities (APD)” means the division in the Department of Human Services (Department) that administers programs for seniors and people with disabilities. This division was formerly named “Seniors and People with Disabilities (SPD).”

(18) “All-Inclusive Rate” or “Bundled Rate” means the nursing facility rate established for a facility. This rate includes all services, supplies, drugs, and equipment as described in OAR 411-070-0085 and in the Division’s Pharmaceutical Services program administrative rules and the Home Enteral/Parenteral Nutrition and IV Services program administrative rules, except as specified in OAR 410-120-1340 Payment.

(19) “Allied Agency” means local and regional governmental agency and regional authority that contracts with the Authority or Department to provide the delivery of services to covered individuals (e.g., local mental health authority, community mental health program, Oregon Youth Authority, Department of Corrections, local health departments, schools, education service districts, developmental disability service programs, Area Agencies on Aging (AAAs), and federally recognized American Indian tribes).

(20) “Alternative Care Settings” means sites or groups of practitioners that provide care to members under contract with a Managed Care Entity (MCE), including urgent care centers, hospice, birthing centers, out-placed medical teams in community or mobile health care facilities, long-term care facilities, and outpatient surgical centers.

(21) “Ambulance” means a specially equipped and licensed vehicle for transporting sick or injured individuals that meets the licensing standards of the Authority or the licensing standards of the state in which the ambulance provider is located.

(22) “Ambulatory Payment Classification” means a reimbursement method that categorizes outpatient visits into groups according to the clinical characteristics, the typical resource use, and the costs associated with the diagnoses and the procedures performed. The groups are called Ambulatory Payment Classifications (APCs).

(23) “Ambulatory Surgical Center (ASC)” means a facility licensed as an ASC by the Authority.

(24) “American Indian/Alaska Native (AI/AN)” means a member of a federally recognized Indian tribe, band, or group, and an Eskimo or Aleut or other Alaska native enrolled by the Secretary of the Interior pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. 1601, or a person who is considered by the Secretary of the Interior to be an Indian for any purpose.

(25) “American Indian/Alaska Native (AI/AN) Clinic” means a clinic recognized under Indian Health Services (IHS) law or by the Memorandum of Agreement between IHS and the Centers for Medicare and Medicaid Services (CMS).

(26) “Ancillary Services” means services supportive of or necessary for providing a primary service, such as anesthesiology, which is an ancillary service necessary for a surgical procedure.

(27) “Anesthesia Services” means administration of anesthetic agents to cause loss of sensation to the body or body part.

(28) “Appeal” means a request for review of an adverse determination, action or as it relates to an MCE an adverse benefit determination.

(29) “Area Agency on Aging (AAA)” means the designated entity with which the Department contracts to meet the requirements of the Older Americans Act and ORS chapter 410 in planning and providing services to the elderly or elderly and disabled population.

(30) “Asynchronous” means not simultaneous or concurrent in time. For the purpose of this general rule, asynchronous telecommunication technologies for telemedicine or telehealth services may include audio and video, audio without video, client or member portal and may include remote monitoring. “Asynchronous” does not include voice messages, facsimile, electronic mail or text messages.

(31) “At Risk of Homelessness” means a Member who:

(a) Has an income that is 30 percent or less than the area median income where the individual resides according to the most recent available data from the U.S. Department of Housing and Urban Development; and,

(b) Lacks sufficient resources or support networks to prevent their homelessness; and,

(d) At Risk of Homelessness does not include individuals in Category 1 of the HUD Homeless definition (24 CFR 91.5 (1)). Category 1 (also called “literally homeless”) includes people residing in Transitional Housing, as defined in 24 CFR 578.3. Recovery Housing is not Transitional Housing, and a Member in Recovery Housing may be eligible for HRSN Housing Supports.

(32) “Atypical Provider” means an entity able to enroll as a Billing Provider (BP) or rendering provider for medical assistance programs related non-health care services but that does not meet the definition of health care provider for National Provider Identification (NPI) purposes.

(33) “Audiologist” means an individual licensed to practice audiology by the State Board of Examiners for Speech Pathology and Audiology.

(34) “Audiology” means the application of principles, methods, and procedures of measurement, testing, appraisal, prediction, consultation, counseling, and instruction related to hearing and hearing impairment for the purpose of modifying communicative disorders involving speech, language, auditory function, including auditory training, speech reading and hearing aid evaluation, or other behavior related to hearing impairment.

(35) “Audio only” means the use of audio technology, permitting real-time communication between a health care provider and a member for the purpose of diagnosis, consultation or treatment. “Audio only” does not include health services that are customarily delivered by audio telephone technology and customarily not billed as separate services by a health care provider, such as the sharing of laboratory results.

(36) “Automated Voice Response (AVR)” means a computer system that provides information on clients' current eligibility status from the Division by computerized phone response.

(37) “Behavioral Health” means mental health, mental illness, addiction disorders, and substance use disorders.

(38) “Behavioral Health Assessment” means a qualified mental health professional’s determination of a member’s need for mental health services.

(39) “Behavioral Health Case Management” means services provided to members who need assistance to ensure access to mental health benefits and services from local, regional, or state allied agencies or other service providers.

(40) “Behavioral Health Evaluation” means a psychiatric or psychological assessment used to determine the need for mental health or substance use disorder services.

(41) “Benefit Package” means the package of covered health care services for which the client is eligible.

(42) “Billing Agent or Billing Service” means third party or organization that contracts with a provider to perform designated services in order to facilitate an Electronic Data Interchange (EDI) transaction on behalf of the provider.

(43) “Billing Provider (BP)” means an individual, agent, business, corporation, clinic, group, institution, or other entity who submits claims to or receives payment from the Division on behalf of a rendering provider and has been delegated the authority to obligate or act on behalf of the rendering provider.

(44) “Buying Up” means the practice of obtaining client payment in addition to the Division or managed care plan payment to obtain a non-covered service or item. (See OAR 410-120-1350 Buying Up.)

(45) “By Report (BR)" means services designated, as BR requires operative or clinical and other pertinent information to be submitted with the billing as a basis for payment determination. This information must include an adequate description of the nature and extent of need for the procedure. Information such as complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care shall facilitate evaluation.

(46) “Care Coordination” means the act and responsibility of care coordination entities to deliberately organize a client’s services, care activities and information sharing among all participants involved with a client’s care according to the physical, developmental, behavioral, dental, and social needs (including Health Related Social Needs and Social Determinants of Health and Equity) of the client. Care Coordination requirements are described in OAR 410-120-1215, 410-120-1221, 410-120-1225, and in accordance with CFR 438.208.

(47) “Care Plan” means a care plan that is developed for and in collaboration with the member, their family, representatives or guardian; and in consultation with the member’s providers, community supports and services, where applicable, to ensure continuity and coordination of a member’s care according to their needs.

(48) “Care Profile” means the electronic record the Authority or its designee develops and maintains for all members. The care profile is the platform that receives feeds from different data sources used to identify, track and manage a member’s needs and risk level to direct the frequency of the outreach and care coordination activities/opportunities that shall be offered to the member.

(49) “Case Management Services” means services provided to ensure that CCO members obtain health services necessary to maintain physical, mental, and emotional development and oral health. Case management services include a comprehensive, ongoing assessment of medical, mental health, substance use disorder or dental needs plus the development and implementation of a plan to obtain or make referrals for needed medical, mental, chemical dependency, or dental services, referring members to community services and supports that may include referrals to Allied Agencies.

(50) "Center of Excellence (COE)" means a hospital, medical center, or other health care provider that meets or exceeds standards set by the agency for specific treatments or specialty care.

(51) “Child Welfare (CW)” means a division within the Department responsible for administering child welfare programs, including child abuse investigations and intervention, foster care, adoptions, and child safety.

(52) “Children's Health Insurance Program (CHIP)” means a federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered by the Authority.

(53) “Chiropractor” means an individual licensed to practice chiropractic by the relevant state licensing board.

(54) “Chiropractic Services” means services provided by a licensed chiropractor within the scope of practice as defined under state law and federal regulation.

(55) “Citizenship Waived Medical (CWM) Benefit Package” means the coverage and limitations defined in OAR 410-134-0005(2) for individuals who met the eligibility requirements in OAR 410-200-0240(1).

(56) “Citizenship Waived Medical Plus (CWX) Benefit Package” means coverage and limitations described in OAR 410-134-0005(2) for CWM individuals who were pregnant or in their post-partum period and meet the eligibility requirements defined in OAR 410-200-0240(2).

(57) “Claimant” means an individual who has requested a hearing.

(58) “Client” means an individual found eligible to receive OHP health services.

(59) “Clinical Nurse Specialist” means a registered nurse who has been approved and certified by the Board of Nursing to provide health care in an expanded specialty role.

(60) “Clinical Social Worker” means an individual licensed to practice clinical social work pursuant to state law.

(61) “Clinical Record” means the medical, dental, or mental health records of a client or member.

(62) “Clinically Appropriate” means having at least one HRSN Clinical Risk Factor and at least one HRSN Social Risk Factor, each of which must be applicable to the HRSN Service for which the Member is authorized. For example, to determine whether a Member must be authorized to receive Home Changes for Health-Related Supports, the Member must, in addition to belonging to an HRSN Covered Population, have at least one HRSN Clinical Risk Factor and one HRSN Social Risk Factor. HRSN Services are not Clinically Appropriate if they are solely for the convenience or preference of the Member.

(63) “Closed Loop Referral” means the process of exchanging information between and among an MCE, the Oregon Health Authority (which may include its Fee For Service (FFS) Program), a Member, HRSN Service Providers, and other similar organizations, to make referrals and communicate about the status of referrals and services for a Member.

(64) “Comfort Care” means medical services or items that give comfort or pain relief to an individual who has a terminal illness, including the combination of medical and related services designed to make it possible for an individual with terminal illness to die with dignity and respect and with as much comfort as is possible given the nature of the illness.

(65) “Community Health Worker” means an individual who:

(a) Has expertise or experience in public health;

(b) Works in an urban or rural community either for pay or as a volunteer in association with a local health care system;

(c) To the extent practicable, shares ethnicity, language, socioeconomic status, and life experiences with the residents of the community where the worker serves;

(d) Assists members of the community to improve their health and increases the capacity of the community to meet the health care needs of its residents and achieve wellness;

(e) Advocates for the individual patient and community health needs, building individual and community capacity to advocate for their health;

(f) Provides health education and information that is culturally appropriate to the individuals being served;

(g) Assists community residents in receiving the care they require;

(h) May give peer counseling and guidance on health behaviors; and

(i) May provide direct services such as first aid or blood pressure screening.

(66) “Community Information Exchange” and “CIE” each means a technology system used by a network of collaborative partners to exchange information for the purpose of connecting individuals to the services and supports they need. CIE functionality must include Closed Loop Referrals, a shared resource directory, and documentation of consent to the use of technology by the Member or other individual being connected to services.

(67) “Community Mental Health Program (CMHP)” means the organization of all services for individuals with mental or emotional disorders operated by, or contractually affiliated with, a local Mental Health Authority operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with the Authority.

(68) “Community Partner” means an individual affiliated with an organization contracted, trained, and certified by the Oregon Health Authority’s Community Partner Outreach Program to provide free assistance to people applying for health coverage in Oregon that includes but is not limited to:

(a) Health coverage application;

(b) Help to enroll in health insurance plans;

(d) Healthcare System Navigation defined in OAR 410-120-0000; and

(e) Outreach and engagement related to subsections (a) through (d) of this section (6).

(69) “Co-morbid Condition” means a medical condition or diagnosis coexisting with one or more other current and existing conditions or diagnoses in the same patient.

(70) “Condition-Specific Program” and “Condition-Specific Facility” mean programs or facilities that treat a narrowly defined illness, disorder or condition, such as:

(a) Behavioral and Mental Health conditions, Substance Use Disorder (SUD) or addiction, including but not limited to:

(A) Alcohol;

(B) Illicit drugs; and

(b) Physical Health conditions, including but not limited to:

(A) Cancer;

(B) Diabetes;

(71) “Condition/Treatment Pair” means diagnoses described in the International Classification of Diseases Clinical Modifications, 10th edition (ICD-10-CM); the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; and treatments described in the Current Procedural Terminology (CPT); or American Dental Association Codes (CDT) or the Authority Behavioral Health Fee Schedule, that, when paired by the Health Evidence Review Commission (HERC), constitute the line items in the Prioritized List of Health Services. Condition/treatment pairs may contain many diagnoses and treatments.

(72) “Contested Case Hearing” means a proceeding before the Authority under the Administrative Procedures Act when any of the following contests an adverse determination, action, or as it relates to an MCE enrollee, an adverse benefit determination:

(a) A client or member or their representative;

(b) A member of an MCE after resolution of the MCE’s appeal process;

(d) An MCE.

(73) “Contiguous Area” means the area up to 75 miles outside the border of the State of Oregon.

(74) “Contiguous Area Provider” means a provider practicing in a contiguous area.

(75) “Continuing Treatment Benefit” means a benefit for clients who meet criteria for having services covered that were either in a course of treatment or scheduled for treatment the day immediately before the date the client’s benefit package changed to one that does not cover the treatment.

(76) “Coordinated Care Organization (CCO)” has the meaning given that term in OAR 410-141-3500(21).

(77) “Co-Payments” means the portion of a claim or medical, dental, or pharmaceutical expense that a client must pay out of their own pocket to a provider or a facility for each service. It is usually a fixed amount that is paid at the time service is rendered. (See OAR 410-120-1230 Client Copayment.)

(78) “Cost Effective” means the lowest cost health service or item that, in the judgment of Authority staff or its contracted agencies, meets the medical needs of the client.

(79) “Cover All Kids (CAK)” meaning defined in OAR 410-200-0015.

(80) “Covered Services” means medically necessary and appropriate health services and items described in ORS chapter 414 and applicable administrative rules. Covered services include:

(a) Services described in the Prioritized List of Health Services above the funding line set by the legislature;

(b) Ancillary Services OAR 410-120-0000 (22);

(d) Services necessary for compliance with the requirements for parity in mental health and substance use disorder benefits in Code of Federal Regulations (CFR) 42 CFR part 438, subpart k; and

(e) Services necessary for compliance with the requirements for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as described in chapter 410 division 151.

(81) “Current Dental Terminology (CDT)” means a listing of descriptive terms identifying dental procedure codes used by the American Dental Association.

(82) “Current Procedural Terminology (CPT)” means a medical code set developed by the American Medical Association used to report medical, surgical, and diagnostic procedures and services performed by physicians and other health care providers.

(83) “Credible Allegation of Fraud” means an allegation for fraud, which has been verified by the Authority or delegate, from any source, including but not limited to: fraud hotline complaints, claims data mining, and patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered to be credible when they have the indicia of reliability and the Agency has reviewed all allegations, facts and evidence carefully and acts judiciously on a case-by-case basis.

(84) “Date of Receipt of a Claim” means the date on which the Authority receives a claim as indicated by the Internal Control Number (ICN) assigned to a claim. Date of receipt is shown as the Julian date in the 5th through 7th position of the ICN.

(85) “Date of Service” means the date on which the client receives medical services or items, unless otherwise specified in the appropriate provider rules. For items that are mailed or shipped by the provider, the date of service is the date on which the order was received, the date on which the item was fabricated, or the date on which the item was mailed or shipped.

(86) “Deactivation” means an action prohibiting a provider’s participation where the Authority assigned provider number is terminated as the result of inactivity, as evidenced by failure to submit claims for eighteen (18) months, or relocation, as evidenced by returned/undeliverable mail by the United States Postal Service or any other mail carrier.

(87) “Declaration for Mental Health Treatment” means a written statement of an individual’s decisions concerning their mental health treatment. The individual makes the declaration when they are able to understand and make decisions related to treatment that is honored when the individual is unable to make such decisions.

(88) “Dental Emergency Services” means dental services provided for severe tooth pain, unusual swelling of the face or gums, or an avulsed tooth.

(89) “Dental Subcontractor” means a prepaid managed care health services organization that enters into a noncomprehensive risk contract with a coordinated care organization (CCO) or the Authority to provide dental services to their Members or, as applicable, Clients enrolled in OHP. Dental Subcontractors contracting with CCOs must perform all delegated activities in accordance with OAR 410-141-3505.

(90) “Dental Therapist” means a person licensed to practice dental therapy within the scope of practice as defined under state law.

(91) “Dentist” means an individual licensed to practice dentistry pursuant to state law of the state in which they practice dentistry or an individual licensed to practice dentistry pursuant to federal law for the purpose of practicing dentistry as an employee of the federal government.

(92) “Denturist” means an individual licensed to practice denture technology pursuant to state law.

(93) “Denturist Services” means services provided within the scope of practice as defined under state law by or under the personal supervision of a denturist.

(94) “Dental Hygienist” means an individual licensed to practice hygiene under the direction of a licensed professional within the scope of practice pursuant to state law.

(95) “Dental Hygienist with an Expanded Practice Permit” means an individual licensed to practice dental hygiene services as authorized by the Board of Dentistry with an Expanded Practice Dental Hygienist Permit (EPDHP) pursuant to state law.

(96) “Dentally Appropriate”

(a) means dental services, items or dental supplies that are:

(A) Recommended by a licensed health provider practicing within the scope of their license; and

(B) Safe, effective and appropriate for the patient based on standards of good dental practice and generally recognized by the relevant scientific or professional community based on the best available evidence; and

(C) Not solely for the convenience or preference of an OHP client, member or a provider of the service, item or dental supply; and

(D) The most cost effective of the alternative levels or types of health services, items or supplies that are covered services that can be safely and effectively provided to a client or member in the Division or MCE’s judgment.

(b) All covered services must be dentally appropriate for the member or client but not all medically appropriate services are covered services.

(97) “Oregon Department of Human Services (Department or ODHS)” means the agency established in ORS chapter 409, including such divisions, programs and offices as may be established therein.

(98) “Department Representative” means an individual who represents the Department and presents the Department’s position in a hearing.

(99) “Diagnosis Code” means as identified in the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM). The primary diagnosis code is shown in all billing claims, unless specifically excluded in individual provider rules. Where they exist, diagnosis codes shall be shown to the degree of specificity outlined in OAR 410-120-1280, Billing.

(100) “Diagnosis Related Group (DRG)” means a system of classification of diagnoses and procedures based on the ICD-10-CM.

(101) “Diagnostic Services” mean those services required to diagnose a condition, including but not limited to: radiology, ultrasound, other diagnostic imaging, electrocardiograms, laboratory and pathology examinations, and physician or other professional diagnostic or evaluative services.

(102) “Dietitian” means an individual licensed by the Board of Licensed Dietitians to provide nutrition services as outlined in the Standards of Practice in the OR Administrative Rules, chapter 834, division 60 (OAR 834-060-0000).

(103) “Division” means the Health Systems Division within the Authority. The Division is responsible for coordinating the medical assistance programs within the State of Oregon including the Oregon Health Plan (OHP) Medicaid demonstration, the State Children's Health Insurance Program (SCHIP-Title XXI), and several other programs.

(104) “Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS)” means equipment that can stand repeated use and is primarily and customarily used to serve a medical purpose. Examples include wheelchairs, respirators, crutches, and custom-built orthopedic braces. Medical supplies are non-reusable items used in the treatment of illness or injury. Examples of medical supplies include diapers, syringes, gauze bandages, and tubing.

(105) “Early and Periodic Screening, Diagnostic and Treatment (EPSDT)” means the program requiring specific coverage for children and young adults, as described in chapter 410 division 151.

(106) “Electronic Data Interchange (EDI)” means the exchange of business documents from application to application in a federally mandated format or, if no federal standard has been promulgated, using bulk transmission processes and other formats as the Authority designates for EDI transactions. For purposes of rules OAR 943-120-0100 through OAR 943-120-0200, EDI does not include electronic transmission by web portal.

(107) “EDI Submitter” means an individual or an entity authorized to establish an electronic media connection with the Authority to conduct an EDI transaction. An EDI submitter may be a trading partner or an agent of a trading partner.

(108) “Electronic Verification System (EVS)” means eligibility information that has met the legal and technical specifications of the Authority in order to offer eligibility information to enrolled providers of the Division.

(109) “Emergency Department” means the part of a licensed hospital facility open 24 hours a day to provide care for anyone in need of emergency treatment.

(110) “Emergency Health Benefit Funding” means funding for the health benefits defined in OAR 410-134-0004(2)(a-j), included in the Healthier Oregon benefits package that is in part funded with state funding and matched with federal funds (42 CFR 440.255).

(111) “Emergency Medical Condition” means a medical condition, whether physical, dental, or behavioral, manifesting itself by acute symptoms of sufficient severity such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to the pregnant person, the health of the person or their pregnancy) in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. An emergency medical condition is not based on the final diagnosis but is based on presenting symptoms as perceived by a prudent layperson and includes cases in which the absence of immediate medical attention would not in fact have had the adverse results described in the previous sentence.

(112) “Emergency Medical Transportation” means transportation necessary for a client with an emergency medical condition as defined in this rule and requires a skilled medical professional such as an Emergency Medical Technician (EMT) and immediate transport to a site, usually a hospital, where appropriate emergency medical service is available.

(113) “Emergency Services” means health services from a qualified provider necessary to evaluate or stabilize an emergency medical condition, including inpatient and outpatient treatment that may be necessary to assure within reasonable medical probability that the patient’s condition is not likely to materially deteriorate from or during a client’s discharge from a facility or transfer to another facility.

(114) “Evidence-Based Medicine” means the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate evaluation of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer. (Source: BMJ 1996; 312:71-72 (13 January)). In addition, Evidence-Based Medicine considers the quality of evidence and the confidence that may be placed in findings.

(115) “False Claim” means a claim that a provider knowingly submits or causes to be submitted that contains inaccurate, misleading, or omitted information and such inaccurate, misleading, or omitted information may result, or has resulted, in an overpayment.

(116) “Family Planning Services” means services for clients of child bearing age (including minors who can be considered to be sexually active) who desire such services and that are intended to prevent pregnancy or otherwise limit family size.

(117) "Federally Supported Hemophilia Treatment Center" means a hemophilia treatment center (HTC) that:

(a) Receives funding from the U.S. Department of Health and Human Services, Maternal and Child Health Bureau National Hemophilia Program;

(b) Is qualified to participate in 340B discount purchasing as an HTC;

(c) Actively participates in the U.S. Center for Disease Control (CDC) and Prevention surveillance and has an identification number that is listed in the HTC directory on the CDC website;

(d) Is recognized by the Federal Regional Hemophilia Network that includes the State of Oregon; and

(e) Is a direct care provider offering comprehensive hemophilia care consistent with treatment recommendations set by the Medical and Scientific Advisory Council (MASAC) of the National Hemophilia Foundation in their standards and criteria for the care of persons with congenital bleeding disorders.

(118) “Federally Qualified Health Center (FQHC)” means a federal designation for a medical entity that receives grants under Section 329, 330, or 340 of the Public Health Service Act or a facility designated as an FQHC by Centers for Medicare and Medicaid (CMS) upon recommendation of the U.S. Public Health Service.

(119) “Fee-for-Service Provider” means a health care provider who is not reimbursed under the terms of an Authority contract with a Coordinated Care Organization or Prepaid Health Plan (PHP). A medical provider participating in a PHP or a CCO may be considered a fee-for-service provider when treating clients who are not enrolled in a PHP or a CCO.

(120) “For Cause Termination” means a mandatory or discretionary termination by the Authority as is outlined in OAR 410-120-1400.

(121) “Fraud” means an intentional deception or misrepresentation made by an individual with the knowledge that the deception may result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable federal or state law.

(122) “Fruit and Vegetable Benefit” means a service that allows a HRSN Fruit and Vegetable Authorized Member (as that term is defined in this rule) to obtain or otherwise receive fruits and vegetables, including herbs, from an HRSN Service Vendor or HRSN Service Provider. The Fruit and Vegetable Benefit includes fresh, frozen, pureed, dried or canned (or any combination of fresh, frozen, dried, pureed or canned) fruits and vegetables, as well as herbs. The Fruit and Vegetable Benefit is one of several discrete benefits that comprise the Nutrition-Related Supports, which is an HRSN Service.

(123) “Fruit and Vegetable Benefit Card” means a service that allows an HRSN Fruit and Vegetable Authorized Member to purchase the Fruit and Vegetable Benefit from participating food retailers, vendors, or farms, or any combination of them, while utilizing an approved Fruit and Vegetable Benefit retail card obtained from a vendor that is enrolled with OHA as an HRSN Service Provider.

(124) “Fruit and Vegetable Box” means one of the Fruit and Vegetable Benefits that consists of pre-selected, pre-packaged fruit and vegetables that an HRSN Fruit and Vegetable Authorized Member obtains from an HRSN Fuit and Vegetable Service Vendor or Service Provider. Depending on which HRSN Fruit and Vegetable Service Vendor or Service Provider a CCO or the Authority works with, the HRSN Fruit and Vegetable Authorized Member may have the Fruit and Vegetable Box delivered to them by the HRSN Fruit and Vegetable Service Vendor or, if available, the Member may be able to pick up the box from the HRSN Fruit and Vegetable Service Vendor or HRSN Service Provider.

(125) “Fully Dual Eligible” means for the purposes of Medicare Part D coverage (42 CFR 423.772), Medicare clients who are also eligible for Medicaid, meeting the income and other eligibility criteria adopted by the Authority for full medical assistance coverage.

(126) “General Assistance (GA)” means medical assistance administered and funded 100 percent with State of Oregon funds through OHP.

(127) “Grievance” means an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee’s rights regardless of whether remedial action is requested.

(128) “Health Care Interpreter” Certified or Qualified have the meaning given those terms in ORS 413.550.

(129) “Health Care Professionals” means individuals with current and appropriate licensure, certification, or accreditation in a medical, mental health, or dental profession who provide health services, assessments, and screenings for clients within their scope of practice, licensure, or certification.

(130) “Healthcare Common Procedure Coding System (HCPCS)” means a method for reporting health care professional services, procedures, and supplies. HCPCS consists of the Level l — American Medical Association's Physician's Current Procedural Terminology (CPT), Level II — National codes, and Level III — Local codes. The Division uses HCPCS codes; however, the Division uses current Dental Terminology (DT) codes for the reporting of dental care services and procedures.

(131) “Healthcare System Navigation” means the process by which a Community Partner supports individuals who are in need of health care by:

(a) Assisting with application for or renewal of Oregon Health Plan (OHP);

(b) Assisting with the management of the application process for OHP;

(d) Identifying and removing barriers to care;

(e) Providing the information needed to build the knowledge and confidence necessary for utilizing benefits; or

(f) Promoting the establishment of healthcare services and continuity of care.

(132) “Health Evidence Review Commission” means a commission that, among other duties, develops and maintains a list of health services ranked by priority from the most to the least important representing the comparative benefits of each service to the population served.

(133) “Health Insurance Portability and Accountability Act of 1996 (HIPAA)” means the federal law (Public Law 104-191, August 21, 1996) with the legislative objective to assure health insurance portability, reduce health care fraud and abuse, enforce standards for health information, and guarantee security and privacy of health information.

(134) “Health Maintenance Organization (HMO)” means a public or private health care organization that is a federally qualified HMO under Section 1310 of the U.S. Public Health Services Act. HMOs provide health care services on a capitated, contractual basis.

(135) “Health Plan New/non-categorical client (HPN)” means an individual who is 19 years of age or older, is not pregnant, is not receiving Medicaid through another program, and who must meet all eligibility requirements to become an OHP client.

(136) “Healthier Oregon” means the medical assistance benefit package that is equal to the OHP Plus benefit package defined in OAR 410-120-1210. The Healthier Oregon is for individuals;

(a) Who do not meet the citizenship and non-citizen status requirements defined in OAR 410-200-0215 and OAR 461-120-0110; and

(b) Who do meet the financial and other non-financial eligibility requirements for a Health Systems Division (HSD) Medical Program (see OAR chapter 410 division 200) or an Oregon Supplemental Income Program Medical (OSIPM) Program (see OAR chapter 461).

(137) “Health-Related Social Needs” and “HRSN” each means the unmet, housing, nutrition, and outreach and engagement-related social needs, that contribute to an individual’s poor health and are a result of underlying social and structural determinants of health.

(138) “Health Risk Assessment (HRA)” means a survey or questionnaire administered verbally, digitally or in writing, to collect information from a member, their representative or guardian about key areas of the member’s health, including their physical, developmental, behavioral, oral and social needs (including Health Related Social Needs and Social Determinants of Health and Equity). The HRA is intended to inform the coordination of services and supports that meet the members individualized needs.

(139) “Hearing Aid Dealer” means an individual licensed by the Board of Hearing Aid Dealers to sell, lease, or rent hearing aids in conjunction with the evaluation or measurement of human hearing and the recommendation, selection, or adaptation of hearing aids.

(140) “Home Changes for Health During Extreme Weather Supports” means health-related devices delivered, and as applicable installed or serviced (or both) by HRSN Service Vendors or HRSN Service Providers in the home of an HRSN-Home Changes for Health Authorized Member (as that term is defined in this rule). “Home Changes for Health” has the same meaning.

(a) Clinically Appropriate home changes for health devices include:

(A) Air conditioners for individuals at health risk due to significant heat;

(B) Heaters for individuals at increased health risk due to significant cold;

(C) Air filtration devices and, as needed, replacement air filters for individuals at health risk due to compromised air quality;

(D) Mini refrigeration units as needed for individuals to store their medications; and

(E) Portable power supplies (PPSs) for individuals who utilize and need to have access to medically necessary electricity-dependent equipment (e.g., ventilators, dialysis machines, intravenous equipment, chair lifts, mobility devices, communication devices, etc.) or are at risk of public safety power shutoffs that could prevent or interfere with their ability to use medically necessary devices.

(b) Home Changes for Health services include, as may be needed by the Member, the provision and service delivery, and, as needed, installation of all the Home Changes for Health devices (identified in (a)(A)– (E) above in this rule) and device maintenance.

(141) “Home Changes for Safety” means home modifications or remediations that are made by an HRSN Services Vendorfor the purpose of eliminating known home-based health and safety risks and ensuring the HRSN Home Changes for Safety Authorized Member’s living environment meets that Member’s functional, health, or safety needs. The term “Home Modifications and Remediations” has the same meaning.

(142) “Home Enteral Nutrition” means services provided in the client's place of residence to an individual who requires nutrition supplied by tube into the gastrointestinal tract as described in the Home Enteral/Parenteral Nutrition and IV Services program provider rules.

(143) “Home Health Agency” means a public or private agency or organization that has been certified by Medicare as a Medicare home health agency and that is licensed by the Authority as a home health agency in Oregon and meets the capitalization requirements as outlined in the Balanced Budget Act (BBA) of 1997.

(144) “Home Health Services” means part-time or intermittent skilled nursing services, other therapeutic services (physical therapy, occupational therapy, speech therapy), and home health aide services made available on a visiting basis in a place of residence used as the client's home.

(145) “Home Intravenous Services” means services provided in the client's place of residence to an individual who requires that medication (antibiotics, analgesics, chemotherapy, hydrational fluids, or other intravenous medications) be administered intravenously as described in the Home Enteral/Parenteral Nutrition and IV Services program administrative rules.

(146) “Home Parenteral Nutrition” means services provided in the client's residence to an individual who is unable to absorb nutrients via the gastrointestinal tract, or for other medical reasons, requires nutrition be supplied parenterally as described in the Home Enteral/Parenteral Nutrition and IV Services program administrative rules.

(147) “Hospice” means a public agency or private organization or subdivision of either that is primarily engaged in providing care to terminally ill individuals and is certified by the federal Centers for Medicare and Medicaid Services as a program of hospice services meeting current standards for Medicare and Medicaid reimbursement and Medicare Conditions of Participation and is currently licensed by the Oregon Health Authority, Public Health Division.

(148) “Hospital” means a facility licensed by the Public Health Division as a general hospital that meets requirements for participation in OHP under Title XVIII of the Social Security Act. The Division does not consider facilities certified by CMS as religious non-medical facilities as hospitals for reimbursement purposes. Out-of-state hospitals shall be considered hospitals for reimbursement purposes if they are licensed as a short-term acute care or general hospital by the appropriate licensing authority within that state and if they are enrolled as a provider of hospital services with the Medicaid agency within that state.

(149) “Hospital-Based Professional Services” means professional services provided by licensed practitioners or staff based on a contractual or employee/employer relationship and reported as a cost on the Hospital Statement of Reasonable Cost report for Medicare and the Calculation of Reasonable Cost (DMAP 42) report for the Division.

(150) “Hospital Dentistry” means dental services normally done in a dental office setting, but due to specific client need (as detailed in OAR chapter 410 division 123) are provided in an ambulatory surgical center or inpatient or outpatient hospital setting under general anesthesia (or IV conscious sedation, if appropriate).

(151) “Hospital Laboratory” means a laboratory providing professional technical laboratory services as outlined under laboratory services in a hospital setting as either an inpatient or outpatient hospital service whose costs are reported on the hospital’s cost report to Medicare and to the Division.

(152) “Housing-Related Supports” means housing services provided to Members authorized to receive one or more of the HRSN Housing-Related Supports service categories to help them maintain healthy and safe housing (as detailed in OAR 410-120-2005). Housing-Related Supports include:

(a) Rent and Utility financial assistance (past due and prospective)

(b) Hotel/Motel Stays

(d) Utilities Set Up

(e) Storage Fees (past due and prospective)

(f) Tenancy Services (paid via 15-minute increments)

(g) Tenancy Services (paid per member per month)

(h) Home Changes for Safety

(i) Home Changes for Health

(153) “HRSN Authorized Member” means a Member who has participated in an HRSN Eligibility Screening and has been approved by the MCE or, as applicable, the Authority, to receive one or more HRSN Services. Members who have been authorized for a specific HRSN Service may be identified by the specific HRSN service or benefit that they have been authorized to receive such as, without limitation, “HRSN Fruit and Vegetable Authorized Member” or “HRSN Rent and Utility Authorized Member” or “HRSN Tenancy Supports Authorized Member.”

(154) “HRSN Clinical Risk Factor” is the generic term to describe the clinical risk a Member must have in order to be eligible for an HRSN service. All HRSN Clinical Risk Factors are identified in OAR 410-120-2005 in Tables 1 through 3 and include the following:

(a) Table 1: Home Changes for Health Device-Specific and Outreach and Engagement Clinical Risk Factors

(b) Table 2: Home Modifications and Remediations, Tenancy Supports, Nutrition Supports, and Outreach and Engagement Clinical Risk Factors

(155) “HRSN Connector” means any person or entity, including HRSN Service Providers and other similar social service organizations, that assists Members in documenting the information necessary to make an HRSN Request to an MCE for an HRSN Eligibility Screening and HRSN Service authorization.

(156) “HRSN Covered Populations” means Members, excluding Members receiving the BRG service package defined in OAR 410-115-0030, who belong to one or more of the following populations, which are further defined in this OAR 410-120-0000:

(a) Adults and Youth Discharged from an Institution for Mental Diseases (IMD); residential mental health and substance use disorder facility, or inpatient psychiatric unit

(b) Adults and Youth Released from Incarceration

(d) Individuals Transitioning to Dual Medicaid and Medicare Status

(e) Individuals who meet the definition of “HUD Homeless”

(f) Individuals who meet the definition of “At Risk of Homelessness”

(g) Individuals identified as “Young Adults with Special Health Care Needs”

(157) “HRSN Eligibility Screening” means the process set out in OAR 410-120-2015, followed by MCEs or, as applicable, the Authority to determine whether a Member meets the criteria necessary for authorizing an HRSN Service.

(158) “HRSN Eligible” means a Member, except for Members receiving the BRG service package defined in OAR 410-115-0030, who meets all of the following criteria:

(a) Belongs to at least one of the HRSN Covered Populations,

(b) Has at least one HRSN Clinical Risk Factor applicable to the HRSN Services,

(d) Meets any additional eligibility criteria and requirements that may apply to a specific HRSN Service all of which are identified in OAR 410-120-2005.

(159) “HRSN Fee Schedule” means the comprehensive list of rates that establishes the maximum allowable reimbursement amount for each HRSN Service. Each service is associated with a unique procedure code and a corresponding procedure code modifier, which are used to correctly identify each service for billing purposes.

(160) “HRSN Outreach and Engagement Services (HRSN O&E Services)” means the activities performed by HRSN Service Providers, the Authority, or MCEs as described in OAR 410-120-2005. HRSN Service Providers shall be compensated for providing HRSN O&E Services when provided to “Presumed HRSN Eligible” Members as described in OAR 410-120-2005.

(161) “HRSN Person-Centered Service Plan” and “HRSN PCSP” each means the HRSN-related component of the care plan that is developed in consultation with the Member upon authorization of HRSN Services as described in OAR 410-120-2025.

(162) “HRSN Self-Attestation” and “Self-Attestation” means an oral or written statement made by the Member or Member Representative that the Member satisfies the applicable requirements necessary to establish the Member is HRSN Eligible to receive one or more HRSN Services. Also see OAR 410-120-2015.

(163) “HRSN Service Provider” means a private or public social service organization, community organization, or other similar individual or entity that provides HRSN Services and meets the qualifications outlined in OAR 410-120-2030 as applicable.

(164) “HRSN Service Request(s)” and “HRSN Request” means a request from an HRSN Connector (an organization or an individual) made to an MCE or, as applicable, the Authority, for the purpose of requesting that the MCE, or as applicable, the Authority, perform an HRSN Eligibility Screening. Some HRSN Requests will be considered complete when the HRSN Connector identifies (i) the name and contact information of the individual who wants to be screened for an HRSN Service and (ii) the anticipated HRSN Service need; however, as described in OAR 410-120-2010, other HRSN Requests will need to identify other information in addition to the name, contact information, and HRSN Service need in order to be considered complete. HRSN Requests may also include confirmation of OHP enrollment, including confirmation of MCE or FFS enrollment, as well as any other information regarding the individual’s potential HRSN Eligibility. The MCE or, as applicable, the Authority, shall be required to document its attempts to collect the information needed to determine eligibility.

(165) “HRSN Service Vendor” means any individual or entity that is contracted or procured by the Authority, an MCE, or an HRSN Service Provider to deliver or provide HRSN Services directly to an HRSN Eligible Member who has been approved to receive HRSN Services. HRSN Service Vendors do not provide HRSN O&E and Tenancy Services. All HRSN Service Vendors that contract directly with the Authority must be enrolled as a Medicaid HRSN Service Provider in accordance with the applicable provisions OAR 410-120-1260. Examples of HRSN Service Vendors include, without limitation, entities, individuals, or organizations that deliver or install air conditioners, heaters, air filtration devices, Portable Power Supplies (PPSs) or mini refrigeration units, as well as home modification vendors, landlords, hotels/motels, chore service providers, utilities and moving companies, pest eradication companies and storage facilities, organizations that assess Members for, plan, prepare, or deliver Medically Tailored Meals and organizations that coordinate, deliver, provide an array of Fruit and Vegetable produce services, and provide an array of Pantry Stocking services including, but not limited to, prepaid produce cards as applicable, usage of vouchers, associated internet platforms, delivery of produce, and produce box programs.

(166) “HRSN Services” means any one of the Home Changes for Health Housing-Related Supports, Nutrition-Related Supports, or HRSN Outreach and Engagement services that address a Member’s Health-Related Social Needs. Additional information regarding the different components of HRSN Services are detailed in OAR 410-120-2005 Tables 4-10 The term “HRSN Benefits” has the same meaning.

(167) “HRSN Social Risk Factor” means the need(s) of a Member related to a Health-Related Social Needs service. The HRSN Social Risk Factors are specific to each of the HRSN Services, which are Home Changes for Health, Housing-Related Supports, Nutrition-Related Supports, and Outreach and Engagement Services. HRSN Social Risk Factors are the following:

(a) HRSN Home Changes for Health Social Risk Factor: A Member who requires a qualifying device to treat, improve, stabilize, or prevent their HRSN Clinical Risk Factor.

(b) HRSN Housing-Related Social Risk Factor: A Member who (i) meets the HUD homeless definition as defined in OAR 410-120-0000, or (ii) is at risk of homelessness as defined in OAR 410-120-0000, or (iii) requires a home modification or remediation service to treat, improve, stabilize, or prevent their HRSN Clinical Risk Factor.

(c) HRSN Nutrition-Related Social Risk Factor: A Member who meets the USDA definition of low food security or very low food security as defined in this OAR 410-120-0000.

(d) HRSN Outreach and Engagement Social Risk Factor: A Member who requires support to obtain or maintain connection with benefit programs, services, or supports for basic needs.

(168) “HUD Homeless” has the meaning assigned to it by the U.S. Department of Housing and Urban Development (HUD) in 24 CFR § 91.5.

(169) “Imminent Eviction” means a tenant has received a court summons or documentation of a similar nature indicating that the eviction process has been initiated.

(170) “Indian Health Care Provider” (IHCP) means an Indian health program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization or an urban Indian organization (otherwise known as an I/T/U) as defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603).

(171) “Indian Health Program” means any Indian Health Service (IHS) facility, any federally recognized tribe or tribal organization, or any FQHC with a 638 designation.

(172) “Indian Health Service (IHS)” means an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS) responsible for providing medical and public health services to members of federally recognized tribes and Alaska Natives.

(173) “Indian Managed Care Entities” (IMCE) means a CCO, MCO, PIHP, PAHP, PCCM, or PCCM entity that is controlled (section 1903(m)(1)(C) of the Act) by the Indian Health Service, a Tribe, Tribal Organization, or Urban Indian Organization, or a consortium, which may be composed of one or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which may also include the Service.

(174) “Indigent” means for the purposes of access to the Intoxicated Driver Program Fund (ORS 813.602), individuals with-out health insurance coverage, public or private, who meet standards for indigence adopted by the federal government as defined in ORS 813.602(5).

(175) “Individual Adjustment Request Form (OHP 1036)” means a form used to resolve an incorrect payment on a previously paid claim, including underpayments or overpayments.

(176) “Individuals Involved with Child Welfare” means Members who are currently, or have previously been, involved in Oregon’s Child Welfare System including Members who are currently or have previously been:

(a) In foster/substitute care;

(b) The recipient of adoption or guardianship assistance;

(d) The subject of an open child welfare case.

(177) “Individuals Transitioning to Dual Status” means Members enrolled in Medicaid who are transitioning to Fully Dual Eligible as defined in this rule. Members who are Individuals Transitioning to Dual Status shall be included in HRSN Covered Population for the ninety (90) calendar days preceding the date Medicare coverage is to take effect and 270 calendar days after it takes effect.

(178) “Inpatient Hospital Services” means services that are furnished in a hospital for the care and treatment of an inpatient. (See Division Hospital Services program administrative rules in chapter 410, division 125 for inpatient covered services.)

(179) “Institutional Level of Income Standards (ILIS)” means three times the amount SSI pays monthly to a person who has no other income and who is living alone in the community. This is the standard used for Medicaid eligible individuals to calculate eligibility for long-term nursing care in a nursing facility, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), and individuals on ICF/IID waivers or eligibility for services under Aging and People with Disabilities (APD) Home and Community Based Services program.

(180) “Institutionalized” means a patient admitted to a nursing facility or hospital for the purpose of receiving nursing or hospital care for a period of thirty (30) days or more.

(181) “International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) (including volumes 1, 2, and 3, as revised annually)” means a book of diagnosis codes used for billing purposes when treating and requesting reimbursement for treatment of diseases.

(182) “Joint Fair Hearing Request” means a request for a fair hearing that is included in an appeal request submitted to an Exchange or other insurance affordability program or appeals entity, in accordance with the signed agreement between the agency and an Exchange or Exchange appeals entity or other program or appeals entity described in 42 CFR 435.1200.

(183) “Laboratory” means a facility licensed under ORS 438 and certified by CMS, Department of Health and Human Services (DHHS), as qualified to participate under Medicare and to provide laboratory services (as defined in this rule) within or apart from a hospital. An entity is considered to be a laboratory if the entity derives materials from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of or the assessment of the health of human beings. If an entity performs even one laboratory test, including waived tests for these purposes, it is considered to be a laboratory under the Clinical Laboratory Improvement Act (CLIA).

(184) “Laboratory Services” means those professional and technical diagnostic analyses of blood, urine, and tissue ordered by a physician or other licensed practitioner of the healing arts within their scope of practice as defined under state law and provided to a patient by or under the direction of a physician or appropriate licensed practitioner in an office or similar facility, hospital, or independent laboratory.

(185) “Licensed Direct Entry Midwife” means a practitioner who has acquired the requisite qualifications to be registered or legally licensed to practice midwifery by the Public Health Division.

(186) “Liability Insurance” means insurance that provides payment based on legal liability for injuries or illness. It includes, but is not limited to, automobile liability insurance, uninsured and underinsured motorist insurance, homeowner’s liability insurance, malpractice insurance, product liability insurance, Worker's Compensation, and general casualty insurance. It also includes payments under state wrongful death statutes that provide payment for medical damages.

(187) “Long-Term Acute Care (LTAC) Hospital” means a facility that provides specialty care designed for patients with serious medical problems that require intense, special treatment for an extended period of time.

(188) “Long-term Care or Long-term Services and Supports” means Medicaid funded Long-term care or long-term services and supports services that include:

(a) “Long-term Care” as defined in OAR 461-001-0000 means the system through which the Department of Human Services provides a broad range of social and health services to eligible adults who are aged, blind, or have disabilities for extended periods of time. This includes nursing homes and behavioral health care outlined in OAR chapter 410, division 172 Medicaid Behavioral Health, including state psychiatric hospitals;

(b) “Long-term Services and Supports” means the Medicaid services and supports provided under a CMS approved waiver to assist individual's needs and to avoid institutionalization as defined in OAR chapter 411, Division 4 and defined as Medicaid Home and Community-Based Settings and Services (HCBS) and as outlined in OAR chapter 410, division 172 (Medicaid Payment for Behavioral Health Services).

(189) "Low Food Security” means reduced quality, variety, or desirability of diet; little or no indication of reduced food intake, as measured by the U.S. Household Food Security Survey Module: Six Item Short Form from the U.S. Department of Agriculture published in May 2024, available here: https://www.ers.usda.gov/media/xxsjnqd1/short2024.pdf

(190) “Managed Care Entity (MCE)” means an entity that enters into a contract to provide services in a managed care delivery system, including but not limited to managed care organizations, prepaid health plans, primary care case managers and Coordinated Care Organizations.

(191) “Managed Care Organization (MCO)” means a contracted health delivery system providing capitated or prepaid health services, also known as a Prepaid Health Plan (PHP). An MCO is responsible for providing, arranging, and making reimbursement arrangements for covered services as governed by state and federal law. An MCO may be a Chemical Dependency Organization (CDO), Dental Care Organization (DCO), Mental Health Organization (MHO), or Physician Care Organization (PCO).

(192) “Managing Employee” means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operations of the provider, whether the provider is an individual, institution, organization or agency.

(193) “Maternity Case Management” means a program available to pregnant clients. The purpose of maternity case management is to extend prenatal services to include non-medical services that address social, economic, and nutritional factors. For more information refer to the Division’s Medical-Surgical Services program administrative rules.

(194) “Meaningful access” means client or member-centered access reflecting the following statute and standards:

(a) Pursuant to Title VI of the Civil Rights Act of 1964, Section 1557 of the Affordable Care Act and the corresponding Federal Regulation at 45 CFR Part 92 and The Americans with Disabilities Act (ADA), providers’ telemedicine or telehealth services shall accommodate the needs of individuals who have difficulty communicating due to a medical condition, who need accommodation due to a disability, advanced age or who have Limited English Proficiency (LEP) including providing access to auxiliary aids and services as described in 45 CFR Part 92;

(b) National Culturally and Linguistically Appropriate Services (CLAS) Standards at https://thinkculturalhealth.hhs.gov/clas/standards; and

(c) As applicable to the client or member, Tribal based practice standards: https://www.oregon.gov/OHA/HSD/AMH/Pages/EBP.aspx;

(d) “Synchronous” means an interaction between a provider and a client or member that occurs at the same time using an interactive technology. This may include audio only, video only, or audio with video and may include remote monitoring.

(195) “Medicaid” means a joint federal and state funded program for medical assistance established by Title XIX of the Social Security Act as amended and administered in Oregon by the Authority.

(196) “Medical Assistance Eligibility Confirmation” means verification through the Electronic Verification System (EVS), AVR, Secure Web site or Electronic Data Interchange (EDI), or an authorized Department or Authority representative.

(197) “Medical Assistance Program” means a program for payment of health services provided to eligible Oregonians, including Medicaid and CHIP services under the OHP Medicaid Demonstration Project and Medicaid and CHIP services under the State Plan, or Healthier Oregon, or Bridge Program, or any other programs that may be prescribed by the Authority from time to time, in accordance with ORS 414.025(17).

(198) “Medical Care Identification” means the card commonly called the “medical card” or medical ID issued to clients (called the Oregon Health ID starting Aug. 1, 2012).

(199) “Medical Services” means care and treatment provided by a licensed medical provider directed at preventing, diagnosing, treating, or correcting a medical problem.

(200) “Medical Transportation” means transportation to or from covered medical services.

(201) “Medically Appropriate”

(a) Means health services, items, or medical supplies that are:

(A) Recommended by a licensed health provider practicing within the scope of their license; and

(B) Safe, effective, and appropriate for the patient based on standards of good health practice and generally recognized by the relevant scientific or professional community based on the best available evidence; and

(C) Not solely for the convenience or preference of an OHP client, member, or a provider of the service item or medical supply; and

(D) The most cost effective of the alternative levels or types of health services, items, or medical supplies that are covered services that can be safely and effectively provided to a Division client or member in the Division or MCE’s judgment.

(b) All covered services must be medically appropriate for the member or client, but not all medically appropriate services are covered services.

(202) “Medically Necessary” means:

(a) Health services and items that are required to address one or more of the following:

(A) The prevention, diagnosis, or treatment of a client or member's disease, condition, or disorder that could result in health impairments or a disability; or

(B) The client’s or member’s ability to achieve age-appropriate growth and development; or

(C) The client’s or member’s ability to attain, maintain, or regain independence in self-care, ability to perform activities of daily living or improve health status; or

(D) The client’s or member’s ability to have access to the benefits of non-institutionalized community living, to achieve person centered care goals, and to live and work in the setting of their choice, when they are receiving Long Term Services or Supports (as defined in these rules);

(b) A medically necessary service must also be medically appropriate. All covered services must be medically necessary, but not all medically necessary services are covered services.

(203) “Medically Tailored Meal” means a fully prepared meal comprised of foods that have been identified, in consultation with a registered dietician nutritionist licensed in the state of Oregon, to meet the specific needs of a Member who has been authorized to receive HRSN Medically Tailed Meals.

(204) “Medicare” means a federally administered program offering health insurance benefits for persons aged 65 or older and certain other aged or disabled persons. This program includes:

(a) Hospital Insurance (Part A) for inpatient services in a hospital or skilled nursing facility, home health care, and hospice care; and

(b) Medical Insurance (Part B) for physicians' services, outpatient hospital services, home health care, end-stage renal dialysis, and other medical services and supplies;

(c) Prescription drug coverage (Part D) means covered Part D drugs that include prescription drugs, biological products, insulin as described in specified paragraphs of section 1927(k) of the Social Security Act, and vaccines licensed under section 351 of the Public Health Service Act. It also includes medical supplies associated with the injection of insulin. Part D covered drugs prohibit Medicaid Title XIX Federal Financial Participation (FFP). For limitations, see the Division’s Pharmaceutical Services program administrative rules in chapter 410, division 121.

(205) “Medical Nutrition Therapy means” an evidence-based application of the Nutrition Care Process provided by licensed dietitians; focused on prevention, delay or management of diseases and conditions; and involving an in-depth assessment, periodic reassessment and intervention(s). (OAR 834-020-0000)

(206) “Medicare Advantage” means an organization approved by CMS to offer Medicare health benefits plans to Medicare beneficiaries.

(207) “Member” means an OHP client enrolled with a pre-paid health plan or coordinated care organization.

(208) “National Correct Coding Initiative (NCCI)” means the Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment.

(209) “National Drug Code or (NDC)” means a universal number that identifies a drug. The NDC number consists of 11 digits in a 5-4-2 format. The Food and Drug Administration assigns the first five digits to identify the manufacturer of the drug. The manufacturer assigns the remaining digits to identify the specific product and package size. Some packages shall display less than 11 digits, but the number assumes leading zeroes.

(210) “National Provider Identification (NPI)” means federally administered provider number mandated for use on HIPAA covered transactions; individuals, provider organizations, and subparts of provider organizations that meet the definition of health care provider (45 CFR 160.103) and who conduct HIPAA covered transactions electronically are eligible to apply for an NPI. Medicare and Medicaid covered entities are required to apply for an NPI.

(211) “Naturopathic physician” means an individual licensed to practice naturopathic medicine by the Oregon Board of Naturopathic Medicine.

(212) “Naturopathic Services” means services provided within the scope of practice as defined under state law and by rules of the Oregon Board of Naturopathic Medicine.

(213) “Non-Billing Provider” also referred to as non-payable, means a provider who is issued a provider number for purposes of rendering, ordering, referring, prescribing, data collection, encounters, or non-claims-use of the Provider Web Portal (e.g., eligibility verification).

(214) “Non-covered Services” means services or items for which the Authority is not responsible for payment or reimbursement. Non-covered services are identified in:

(a) OAR 410-120-1200 Excluded Services and Limitations; and

(b) OAR 410-120-1210 Medical Assistance Benefit Packages and Delivery System;

(d) OAR 410-141-0520 Prioritized List of Health Services; and

(e) Any other applicable Division administrative rules.

(215) “Non-Emergent Medical Transportation Services (NEMT)” means transportation to or from a source of covered service, that does not involve a sudden, unexpected occurrence which creates a medical crisis requiring emergency medical services as defined in OAR 410-120-0000 and requiring immediate transportation to a site, usually a hospital, where appropriate emergency medical care is available.

(216) “Nurse Anesthetist, C.R.N.A.” means a registered nurse licensed in the State of Oregon as a CRNA who is currently certified by the National Board of Certification and Recertification for Nurse Anesthetists.

(217) “Nurse Practitioner” means an individual licensed as a registered nurse and certified by the Board of Nursing to practice as a nurse practitioner pursuant to state law.

(218) “Nurse Practitioner Services” means services provided within the scope of practice of a nurse practitioner as defined under state law and by rules of the Board of Nursing.

(219) “Nursing Facility” means a facility licensed and certified by the Department and defined in OAR 411-070-0005.

(220) “Nursing Services” means health care services provided to a patient by a registered professional nurse or a licensed practical nurse under the direction of a licensed professional within the scope of practice as defined by state law.

(221) “Nutrition Care Plan for HRSN Medically Tailored Meals” means a detailed plan created and documented by a dietitian during the Nutrition Care Process that details how Medically Tailored Meals will be used to treat the HRSN Authorized Member’s nutrition sensitive health condition. The term “HRSN MTM Nutrition Care Plan” has the same meaning.

(222) “Nutrition Care Plan for HRSN Pantry Stocking” means the written description of the service, service duration, and service goals incorporated within the HRSN Pantry Stocking Authorized Member’s Person Centered Service Plan, as outlined in OAR 410-120-2025 4(a)-(h). The term “HRSN Pantry Nutrition Care Plan” has the same meaning.

(223) “Nutrition Care Process” means a systematic method that dietetics and nutrition professionals use to provide nutrition care. It is comprised of four steps: nutrition assessment and reassessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.

(224) “Nutrition-Related Supports” means nutrition services provided to Members who are authorized to receive one or more of the HRSN Nutrition-Related Supports service categories identified in (a) – (d) of this section, for the purpose of improving their access to food and health (as detailed in OAR 410-120-2005 Table 6). Nutrition-Related Supports include the following:

(a) Assessment for HRSN Medically Tailored Meals (if not already authorized, performed, and covered by OHP under the Medically Necessary standard);

(b) Medically Tailored Meals;

(d) Fruit and Vegetable Box and Fruit and Vegetable Benefit Card; and

(e) Pantry Stocking Grocery Box and Pantry Stocking Grocery Benefit Card

(225) “Nutritional Counseling” means counseling that takes place as part of the treatment of an individual with a specific condition, deficiency, or disease such as diabetes, hypercholesterolemia, or phenylketonuria.

(226) “Nutrition Education” means any combination of educational strategies, accompanied by environmental supports, designed to motivate and facilitate voluntary adoption of food choices and other food- and nutrition-related behaviors conducive to health and well-being.

(227) “Occupational Therapist” means an individual licensed by the State Board of Examiners for Occupational Therapy.

(228) “Occupational Therapy” means the functional evaluation and treatment of individuals whose ability to adapt or cope with the task of living is threatened or impaired by developmental deficiencies, physical injury or illness, the aging process, or psychological disability. The treatment utilizes task-oriented activities to prevent or correct physical and emotional difficulties or minimize the disabling effect of these deficiencies on the life of the individual.

(229) “Ombudsman Services” means advocacy services provided by the Authority to clients whenever the client is reasonably concerned about access to, quality of, or limitations on the health services provided.

(230) “Oregon Health ID” means a card the size of a business card that lists the client’s name, client ID (prime number), and the date it was issued.

(231) “Oregon Health Plan (OHP)” means the Medicaid and Children’s Health Insurance (CHIP) Demonstration Project that expands Medicaid and CHIP eligibility beyond populations traditionally eligible for Medicaid to other low-income populations and Medicaid and CHIP services under the State Plan.

(232) “Optometric Services” means services provided within the scope of practice of optometrists as defined under state law.

(233) “Optometrist” means an individual licensed to practice optometry pursuant to state law.

(234) “Oregon Health Authority (Authority)” means the agency established in ORS chapter 413 that administers the funds for Titles XIX and XXI of the Social Security Act. It is the single state agency for the administration of the medical assistance program under ORS chapter 414. For purposes of these rules, the agencies under the authority of the Oregon Health Authority are the Public Health Division, Health Systems Division, External Relations, Health Policy and Analytics, Fiscal and Operations, Health System Division, Office of Equity and Inclusion, and the Oregon State Hospital.

(235) “Oregon Youth Authority (OYA)” means the state department charged with the management and administration of youth correction facilities, state parole and probation services, and other functions related to state programs for youth corrections.

(236) “Out-of-State Providers” means any provider located outside the borders of the State of Oregon:

(a) Contiguous area providers are those located no more than 75 miles from the border of the State of Oregon;

(b) Non-contiguous area providers are those located more than 75 miles from the borders of the State of Oregon.

(237) “Outpatient Hospital Services” means services that are furnished in a hospital for the care and treatment of an outpatient. For information on outpatient-covered services, see the Division’s Hospital Services administrative rules chapter 410, division 125.

(238) “Overdue Claim” means a valid claim that is not paid within 45 days of the date it was received.

(239) “Overpayment” means a payment made by the Authority to a provider in excess of the correct Authority payment amount for a service. Overpayments are subject to repayment to the Authority.

(240) “Overuse” means use of medical goods or services at levels determined by Authority medical staff or medical consultants to be medically unnecessary or potentially harmful.

(241) “Ownership interest” means the possession of equity in the capital, the stock, or the profits of the disclosing entity. A person with an ownership or control interest is a person or corporation that:

(a) Has an ownership interest totaling 5 percent or more in a disclosing entity;

(b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;

(d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;

(e) Is an officer or director of a disclosing entity that is organized as a corporation; or

(f) Is a partner in a disclosing entity that is organized as a partnership.

(242) “Pantry Stocking Benefit” means a service that allows an HRSN Pantry Stocking Authorized member to purchase or receive from an HRSN Service Vendor or HRSN Service Provider an assortment of foods aimed at promoting improved nutrition for that member. Foods available through this service may be fresh, frozen, dried, pureed, or canned and may include herbs.

(243) “Pantry Stocking Benefit Card” means a service that allows an HRSN Pantry Stocking Authorized member to purchase the Pantry Stocking Benefit from participating food retailers, vendors, or farms, or any combination of them, while utilizing an approved Pantry Stocking Benefit retail card obtained from a vendor that is enrolled with OHA as an HRSN Service Provider.

(244) “Pantry Stocking Grocery Box” means one of the Pantry Stocking Benefits that consists of pre-selected, pre-packaged assortment of foods aimed at promoting improved nutrition that the HRSN Pantry Stocking Authorized Member obtains from an HRSN Pantry Stocking Service Vendor or HRSN Service Provider. Depending on which HRSN Pantry Stocking Service Vendor or HRSN Service Provider, a CCO or the Authority works with, the HRSN Pantry Stocking Authorized Member may have the Pantry Stocking Box delivered to them by the HRSN Pantry Stocking Vendor or, if available, the Member may be able to pick up the box from the HRSN Pantry Stocking Service Vendor or HRSN Service Provider.

(245) “Participating provider” means a provider that has a contractual relationship with an MCE. A Participating Provider is not a Subcontractor solely by virtue of a Participating Provider agreement with an MCE. “Network Provider” has the same meaning as Participating Provider.

(246) “Payable Provider” means a provider who is issued a provider number for purposes of submitting medical assistance program claims directly to the Authority for payment.

(247) “Payment Authorization” means authorization granted by the responsible agency, office, or organization for payment prior or subsequent to the delivery of services, as described in these general rules and the appropriate program rules. See the individual program rules for services requiring authorization.

(248) “Peer Review Organization (PRO)” means an entity of health care practitioners of services contracted by the state to review services ordered or furnished by other practitioners in the same professional field.

(249) “Peer Support Specialist” means an individual providing services to another individual who shares a similar life experience such as (i) addiction to addiction, (ii) mental health condition to mental health condition, or (iii) family member of an individual with a mental health condition to family member of an individual with a mental health condition. A peer support specialist shall be a self-identified individual:

(a) Currently or formerly receiving addictions or mental health services;

(b) In recovery from an addiction disorder who meets the abstinence requirements for recovering staff in alcohol or other drug treatment programs;

(250) “Peer Wellness Specialist” including Family Support Specialist and Youth Support Specialist means an individual who is responsible for assessing mental health service and support needs of the individual’s peers through community outreach, assisting individuals with access to available services and resources, addressing barriers to services and providing education and information about available resources and mental health issues in order to reduce stigmas and discrimination toward consumers of mental health services, and to provide direct services to assist individuals in creating and maintaining recovery, health, and wellness.

(251) “Person Centered Care” means care that reflects the individual patient’s strengths and preferences, reflects the clinical needs of the patient as identified through an individualized assessment, is based upon the patient’s goals, and shall assist the patient in achieving the goals.

(252) “Personal Health Navigator” means an individual who provides information, assistance, tools, and support to enable a patient to make the best health care decisions in the patient’s particular circumstances and considering the patient’s needs, lifestyle, combination of conditions, and desired outcome.

(253) “Pharmaceutical Services” means services provided by a pharmacist, including medications dispensed in a pharmacy upon an order of a licensed practitioner prescribing within the scope of practice.

(254) “Pharmacist” means an individual licensed to practice pharmacy pursuant to state law.

(255) “Physical Capacity Evaluation” means an objective, directly observed measurement of a person's ability to perform a variety of physical tasks combined with subjective analysis of abilities of the individual.

(256) “Physical Therapist” means an individual licensed by the relevant state licensing authority to practice physical therapy.

(257) “Physical Therapy” means treatment comprising exercise, massage, heat or cold, air, light, water, electricity, or sound for the purpose of correcting or alleviating any physical or mental disability, or the performance of tests as an aid to the assessment, diagnosis, or treatment of a human being. Physical therapy may not include radiology or electrosurgery.

(258) “Physician” means an individual licensed to practice medicine pursuant to state law of the state in which they practice medicine or an individual licensed to practice medicine pursuant to federal law for the purpose of practicing medicine under a contract with the federal government. A physician may be an individual licensed under ORS 677 or ORS 685.

(259) “Physician Associate" means an individual licensed as a physician associate in accordance with ORS 677. Physician associates provide medical services under the direction and supervision of an Oregon licensed physician according to a practice description approved by the Board of Medical Examiners.

(260) “Physician Services” means services provided within the scope of practice as defined under state law by or under the personal supervision of a physician.

(261) “Podiatric Services” means services provided within the scope of practice of podiatrists as defined under state law.

(262) “Podiatrist” means an individual licensed to practice podiatric medicine pursuant to state law.

(263) “Post-Payment Review” means review of billings or other medical information for accuracy, medical appropriateness, level of service, or for other reasons subsequent to payment of the claim.

(264) “Practitioner” or “Practitioner of the Healing Arts” means an individual licensed pursuant to state law to engage in the provision of health care services within the scope of the practitioner's license or certification.

(265) “Prepaid Health Plan (PHP)” means a managed health, dental, chemical dependency, or mental health organization that contracts with the Authority on a case managed, prepaid, capitated basis under OHP. PHPs may be a Chemical Dependency Organization (CDO), Dental Care Organization (DCO), Mental Health Organization (MHO), or Physician Care Organization (PCO)

(266) “Presumed HRSN Eligible” means an OHP Member who, through Self-Attestation or other information available to the HRSN Service Provider or, as applicable, the Authority or the MCE, is believed to (i) belong to at least one HRSN Covered Population, (ii) have an HRSN Clinical Risk Factor, and (iii) have an HRSN Social Risk Factor. If the Member provides the HRSN Service Provider with Self-Attestation, the Self-Attestation does not need to identify the Member’s specific HRSN Covered Population or their specific HRSN Clinical Risk Factors. For purposes of making a presumption of HRSN Eligibility, it is sufficient that the Member attest that they belong to at least one of the HRSN Covered Populations and have at least one qualifying Clinical Risk Factor. However, the Member must attest to the specific HRSN Service need.

(267) “Primary Care Dentist (PCD)” means a dental practitioner responsible for supervising and coordinating initial and primary dental care within their scope of practice for their members.

(268) “Primary Care Provider (PCP)” means any enrolled medical assistance provider who has responsibility for supervising, coordinating, and providing initial and primary care within their scope of practice for identified clients. PCPs initiate referrals for care outside their scope of practice, consultations, and specialist care and assure the continuity of medically appropriate client care. A Federally qualified PCP means a physician with a specialty or subspecialty in family medicine, general internal medicine, or pediatric medicine as defined in OAR 410-130-0005.

(269) “Prior Authorization (PA)” means payment authorization for specified medical services or items given by Authority staff or its contracted agencies before providing the service. A physician referral is not a PA.

(270) “Prioritized List of Health Services” means the listing of conditions and treatment pairs developed by the Health Evidence Review Commission for the purpose of administering OHP.

(271) “Private Duty Nursing Services” means nursing services provided within the scope of license by a registered nurse or a licensed practical nurse under the general direction of the patient's physician to an individual who is not in a health care facility.

(272) “Provider” means an individual, facility, institution, corporate entity, or other organization enrolled or not enrolled that provides or supplies health services or items, also termed a rendering provider or participating provider, or bills, obligates, and receives reimbursement on behalf of a rendering provider of services, also termed a Billing Provider (BP). The term provider refers to both rendering providers and BP unless otherwise specified.

(273) “Provider Organization” means a group practice, facility, or organization that is:

(a) An employer of a provider, if the provider is required as a condition of employment to turn over fees to the employer; or

(b) The facility in which the service is provided, if the provider has a contract under which the facility submits claims; or

(c) A foundation, plan, or similar organization operating an organized health care delivery system, if the provider has a contract under which the organization submits the claim; and

(d) Such group practice, facility, or organization is enrolled with the Authority, and payments are made to the group practice, facility, or organization;

(e) An agent if such entity solely submits billings on behalf of providers and payments are made to each provider. (See Subparts of Provider Organization.)

(274) “Psychiatric Emergency Services (PES)” means medical and behavioral health services provided to individuals experiencing an acute disturbance of thought, mood, behavior, or social relationship that requires an immediate intervention as defined by the patient, family, or the community to prevent harm to the patient or others.

(275) “Public Health Clinic” means a clinic operated by a county government.

(276) “Public Rates” means the charge for services and items that providers, including hospitals and nursing facilities, made to the general public for the same service on the same date as that provided to Authority clients.

(277) “Public Safety Power Shutoff” and “PSPS” means the temporary shutdown of electricity for the purpose of protecting communities in high fire-risk areas when experiencing extreme weather events, which could cause the electrical system to spark wildfires. The decision to implement a PSPS is usually made by the utility provider of the affected service area.

(278) “Qualified Medicare Beneficiary (QMB)” means a Medicare beneficiary as defined by the Social Security Act and its amendments.

(279) “Qualified Medicare and Medicaid Beneficiary (QMM)” means a Medicare beneficiary who is also eligible for Division coverage.

(280) “Quality Improvement” means the efforts to improve the level of performance of a key process or processes in health services or health care.

(281) “Quality Improvement Organization (QIO)” means an entity that has a contract with CMS under Part B of Title XI to perform utilization and quality control review of the health care furnished, or to be furnished, to Medicare and Medicaid clients; formerly known as a Peer Review Organization.

(282) “Radiological Services” means those professional and technical radiological and other imaging services for the purpose of diagnosis and treatment ordered by a physician or other licensed practitioner of the healing arts within the scope of practice as defined under state law and provided to a patient by or under the direction of a physician or appropriate licensed practitioner in an office or similar facility, hospital, or independent radiological facility.

(283) “Recipient” means an individual who is currently eligible for medical assistance (also known as a client).

(284) “Recreational Therapy” means recreational or other activities that are diversional in nature (includes, but is not limited to, social or recreational activities or outlets).

(285) “Recoupment” means an accounts receivable system that collects money owed by the provider to the Authority by withholding all or a portion of a provider's future payments.

(286) “Reduction of Services” means situations in which the agency authorizes an amount, duration or scope of a service which is less than that requested by the beneficiary or provider. For example, if the individual has requested twenty (20) physical therapy visits and the Division denies the individual’s coverage of twenty (20) visits, covering instead only ten (10) visits—this is considered a denial of a service and could be appealed.

(287) “Reentry FCAA Services” means the defined set of existing Medicaid and CHIP services that must be provided to Members who are FCAA-Covered Youth, as defined in OAR 410-155-0000 and 410-155-0010. Reentry FCAA Services include:

(a) Screening and diagnostic services in the thirty (30) days prior to release, or no later than one week, or as soon as practicable, after release; and

(b) Targeted Case Management in the thirty (30) days prior to release and for at least thirty (30) days post-release (as defined in OAR 410-138-0000).

(288) “Referral” means the transfer of total or specified care of a client from one provider to another. As used by the Authority, the term referral also includes a request for a consultation or evaluation or a request or approval of specific services. In the case of clients whose medical care is contracted through a Prepaid Health Plan (PHP), or managed by a Primary Care Physician, a referral is required before non-emergency care is covered by the PHP or the Authority.

(289) “Remittance Advice (RA)” means the automated notice a provider receives explaining payments or other claim actions. It is the only notice sent to providers regarding claim actions.

(290) “Rendering provider” means an individual, facility, institution, corporate entity, or other organization that supplies health services or items, also termed a provider, or bills, obligates, and receives reimbursement on behalf of a provider of services, also termed a billing provider (BP). The term rendering provider refers to both providers and BP unless otherwise specified.

(291) “Request for Hearing” means a clear expression in writing by an individual or representative that the individual wishes to appeal a Department or Authority decision or action and wishes to have the decision considered by a higher authority.

(292) “Representative” means an individual who can make OHP-related decisions for a client who is not able to make such decisions themselves.

(293) “Retroactive Medical Eligibility” means eligibility for medical assistance granted to a client retroactive to a date prior to the client's application for medical assistance.

(294) “Ride” means non-emergent medical transportation services for a client either to or from a location where covered services are provided. “Ride” does not include client-reimbursed medical transportation or emergency medical transportation in an ambulance.

(295) “Rural” means a geographic area that is ten or more map miles from a population center of 30,000 people or less.

(296) “Sanction” means an action against providers taken by the Authority in cases of misuse or abuse of Oregon Health Authority requirements or fraud, waste and abuse, in accordance with OAR 410-120-1400.

(297) “School Based Health Service” means a health service required by an Individualized Education Plan (IEP) during a child's education program that addresses physical or mental disabilities as recommended by a physician or other licensed practitioner.

(298) “Self-Sufficiency” means the division in the Department of Human Services that administers programs for adults and families.(299) “Service Agreement” means an agreement between the Authority and a specified provider to provide identified services for a specified rate. Service agreements may be limited to services required for the special needs of an identified client. Service agreements do not preclude the requirement for a provider to enroll as a provider.

(299) “Service Authorization Request” means a member’s initial or continuing request for the provision of a service including member requests made by their provider or the member’s authorized representative.

(300) “Service location” means the location of a provider when services are rendered.

(301) “Sliding Fee Schedule” means a fee schedule with varying rates established by a provider of health care to make services available to indigent and low-income individuals. The sliding-fee schedule is based on ability to pay.

(302) “Social Worker” means an individual licensed by the Board of Clinical Social Workers to practice clinical social work.

(303) "Special Health Care Needs (SHCN)” means individuals of any age who experience or exhibit signs of developing;

(a) Physical, functional, intellectual or developmental disabilities; or

(b) Long-standing or chronic medical condition(s); or

(c) Complex behavioral health conditions, including “Substance Use Disorders” or “Serious and Persistent Mental Illness;” or

(d) Live with other health or social conditions placing them at risk, that without intervention will likely cause negative impact to an individual's health or wellbeing.

(304) “Speech-Language Pathologist” means an individual licensed by the Oregon Board of Examiners for Speech Pathology.

(305) “Speech-Language Pathology Services” means the application of principles, methods, and procedure for the measuring, evaluating, predicting, counseling, or instruction related to the development and disorders of speech, voice, or language for the purpose of preventing, habilitating, rehabilitating, or modifying such disorders in individuals or groups of individuals.

(306) “State Facility” means a hospital or training center operated by the State of Oregon that provides long-term medical or psychiatric care.

(307) “Supplemental Health Benefit State Funding” means funding for the health benefits included in the Healthier Oregon benefits package described in OAR 410-134-0004(3)(a-m).

(308) “Subparts (of a Provider Organization)” means for NPI application, subparts of a health care provider organization may meet the definition of health care provider (45 CFR 160.103) if it were a separate legal entity and if it conducted HIPAA-covered transactions electronically or has an entity do so on its behalf and could be components of an organization or separate physical locations of an organization.

(309) “Subrogation” means right of the state to stand in place of the client in the collection of Third-Party Resources (TPR).

(310) “Substance Use Disorder (SUD) Services” means assessment, treatment, and rehabilitation on a regularly scheduled basis or in response to crisis for alcohol or other drug abuse for dependent members and their family members or significant others, consistent with Level I, Level II, or Level III of the most currently published edition of the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC). SUD is an interchangeable term with Chemical Dependency (CD), Alcohol and other Drug (AOD), and Alcohol and Drug (A & D).

(311) “Supplemental Security Income (SSI)” means a program available to certain aged and disabled persons that is administered by the Social Security Administration through the Social Security office.

(312) “Surgical Assistant” means an individual performing required assistance in surgery as permitted by rules of the State Board of Medical Examiners.

(313) “Suspension” means a temporary sanction prohibiting a provider's participation in the medical assistance programs by suspending the provider's Authority-assigned provider number for a specified period of time for one or more of the reasons in OAR 410-120-1400. No payments, Title XIX, or State Funds shall be made for services provided while the provider is suspended.

(314) “Targeted Case Management (TCM)” means activities that assist the client in a target group in gaining access to needed medical, social, educational, and other services. This includes locating, coordinating, and monitoring necessary and appropriate services. TCM services are often provided by allied agency providers.

(315) “Telecommunication technologies” means the use of devices and services for telemedicine or telehealth delivered services. These technologies include videoconferencing, store-and-forward imaging, streaming media including services with information transmitted via landlines, and wireless communications, including the Internet and telephone networks.

(316) “Telehealth” includes telemedicine and includes the use of electronic information and telecommunications technologies to support remote clinical healthcare, client or member and professional health-related education, public health, and health administration.

(317) “Telemedicine” means the mode of delivering remote clinical health services using information and telecommunication technologies to provide consultation and education or to facilitate diagnosis, treatment, care management or self-management of a client or member’s healthcare.

(318) “Termination” means a sanction prohibiting a provider's participation in the Authority’s programs by canceling the provider's Authority-assigned provider number and provider agreement for one or more of the reasons in OAR 410-120-1400 and the provider has exhausted all applicable appeal rights or the timeline for appeal has expired. No payments, Title XIX, or state funds shall be made for services provided after the date of termination. Termination is permanent unless:

(a) The exceptions to mandatory exclusion are met; or

(b) Otherwise stated by the Authority at the time of termination.

(319) “Third Party Liability (TPL), Third Party Resource (TPR), or Third party payer” means a medical or financial resource that, under law, is available and applicable to pay for medical services and items for an Authority client.

(320) “Traditional Health Worker” means a community health worker, peer wellness specialist, personal health navigator, peer support specialist, birth doula, or other similar health workers not regulated or certified by the State of Oregon.

(321) “Transportation” means medical transportation.

(322) “Trauma informed approach” means approach undertaken by providers and healthcare or human services programs, organizations, or systems in providing mental health and substance use disorders treatment where there is a recognition and understanding of the signs and symptoms of trauma in, and the intensity of such trauma on, individuals, families, and others involved within a program, organization, or system, and then takes into account those signs, symptoms, and their intensity and fully integrates that knowledge when implementing and providing potential paths for recovery from mental health or substance use disorders. The Trauma Informed Approach also means that providers and healthcare or human services programs, organizations, or systems actively resist re-traumatization of the individuals being served within their respective entities.

(323) “Trauma Informed Services” means those services provided using a trauma informed approach.

(324) “Type A Hospital” means a hospital identified by the Office of Rural Health as a Type A hospital.

(325) “Type B AAA” means an AAA administered by a unit or combination of units of general purpose local government for overseeing Medicaid, financial and adult protective services, and regulatory programs for the elderly or the elderly and disabled.

(326) “Type B AAA Unit” means a Type B AAA funded by Oregon Project Independence (OPI), Title III—Older Americans Act, and Title XIX of the Social Security Act.

(327) “Type B Hospital” means a hospital identified by the Office of Rural Health as a Type B hospital.

(328) “Urban” means a geographic area that is less than ten map miles from a population center of 30,000 people or more.

(329) “Urgent Care Services” means health services that are medically appropriate and immediately required to prevent serious deterioration of a client’s health that are a result of unforeseen illness or injury.

(330) “Usual Charge (UC)” means the lesser of the following unless prohibited from billing by federal statute or regulation:

(a) The provider's charge per unit of service for the majority of non-medical assistance users of the same service based on the preceding month's charges;

(b) The provider's lowest charge per unit of service on the same date that is advertised, quoted, or posted. The lesser of these applies regardless of the payment source or means of payment;

(c) Where the provider has established a written sliding fee scale based upon income for individuals and families with income equal to or less than 200 percent of the federal poverty level, the fees paid by these individuals and families are not considered in determining the usual charge. Any amounts charged to Third Party Resources (TPR) are to be considered.

(331) “Utilization Review (UR)” means the process of reviewing, evaluating, and assuring appropriate use of medical resources and services. The review encompasses quality, quantity, and appropriateness of medical care to achieve the most effective and economic use of health care services.

(332) “Valid Claim” means an invoice received by the Division or the appropriate Authority or Department office for payment of covered health care services rendered to an eligible client that:

(a) Can be processed without obtaining additional information from the provider of the goods or services or from a TPR; and

(b) Has been received within the time limitations prescribed in these General Rules (OAR chapter 410 division 120).

(333) “Valid Preauthorization” means a document the Authority, a PHP, or CCO receives requesting a health service for a member who may be eligible for the service at the time of the service, and the document contains:

(a) A beginning and ending date not exceeding twelve months, except for cases of PHP or CCO enrollment where four months may apply; and

(b) All data fields required for processing the request or payment of the service including the appropriate billing codes.

(334) “Very Low Food Security” means reports of multiple indications of disrupted eating patterns and reduced food intake, as measured by the U.S. Household Food Security Survey Module: Six Item Short Form from the U.S. Department of Agriculture published in May 2024, available here: https://www.ers.usda.gov/sites/default/files/_laserfiche/DataFiles/50764/short2024.pdf

(335) “Vision Services” means provision of corrective eyewear, including ophthalmological or optometric examinations for determination of visual acuity and vision therapy and devices.

(336) “Volunteer” (for the purposes of NEMT) means an individual selected, trained and under the supervision of the Department who is providing services on behalf of the Department in a non-paid capacity except for incidental expense reimbursement under the Department Volunteer Program authorized by ORS 409.360.

(337) “Young Adults with Special Health Care Needs (YSHCN)” means a program that provides young adults who meet pre-determined social and clinical criteria with supplementary benefits, in addition to OHP Plus or Healthier Oregon coverage. The supplementary benefits include EPSDT services, HRSN services, and extended vision and dental services. The YSHCN program is more fully described in OAR 410-200-0455.

History

Statutory/Other Authority: ORS 413.042, ORS 414.065 & 414.231
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 25-2026, amend filed 06/26/2026, effective 07/01/2026
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 2-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024
DMAP 130-2024, amend filed 10/24/2024, effective 11/01/2024
DMAP 118-2024, amend filed 08/26/2024, effective 08/26/2024
DMAP 93-2024, amend filed 05/24/2024, effective 05/24/2024
DMAP 77-2024, amend filed 03/15/2024, effective 03/15/2024
DMAP 73-2024, minor correction filed 02/29/2024, effective 02/29/2024
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 99-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 84-2023, amend filed 11/30/2023, effective 12/01/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 14-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 9-2023, amend filed 03/06/2023, effective 03/06/2023
DMAP 7-2023, minor correction filed 03/01/2023, effective 03/01/2023
DMAP 96-2022, amend filed 12/28/2022, effective 01/01/2023
DMAP 67-2022, minor correction filed 08/15/2022, effective 08/15/2022
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 29-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 62-2017, amend filed 12/28/2017, effective 01/01/2018
DMAP 77-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 63-2016(Temp), f. & cert. ef. 11-10-16 thru 5-8-17
DMAP 31-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 30-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 55-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 29-2015, f. & cert. ef. 5-29-15
DMAP 5-2015, f. & cert. ef. 2-10-15
DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14
DMAP 71-2013, f. & cert. ef. 12-27-13
DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru 12-24-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
DMAP 11-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 13-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 24-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04
OMAP 62-2003, f. 9-8-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 42-2002, f. & cert. ef. 10-1-02
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 11-2000, f. & cert. ef. 6-23-00
OMAP 31-1999, f. & cert. ef. 10-1-99
OMAP 10-1999, f. & cert. ef. 4-1-99
OMAP 20-1998, f. & cert. ef. 7-1-98
HR 21-1997, f. & cert. ef. 10-1-97
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 40-1994, f. 12-30-94, cert. ef. 1-1-95
HR 31-1994, f. & cert. ef. 11-1-94
HR 2-1994, f. & cert. ef. 2-1-94
HR 32-1993, f. & cert. ef. 11-1-93
HR 41-1991, f. & cert. ef. 10-1-91
HR 25-1991(Temp), f. & cert. ef. 7-1-91
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0005; AFS 69-1988, f. & cert. ef. 12-5-88
AFS 7-1988, f. & cert. ef. 2-1-88
AFS 13-1987, f. 3-31-87, cert. ef. 4-1-87
AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85
AFS 37-1984, f. 8-30-84, cert. ef. 9-1-84
AFS 13-1984(Temp), f. & cert. ef. 4-2-84
AFS 12-1984, f. 3-16-84, cert. ef. 4-1-84
AFS 4-1984, f. & cert. ef. 2-1-84
AFS 81-1982, f. 8-30-82, cert. ef. 9-1-82
AFS 57-1982, f. 6-28-82, cert. ef. 7-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 33-1981, f. 6-23-81, cert. ef. 7-1-81
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81

Or. Admin. R. 410-120-0001 Interpreter Services

(1) Health care providers are required to provide health care language interpreter services for Medicaid members with Limited English Proficiency (LEP) and communication services for people who are deaf and hard of hearing pursuant to Title VI of the Civil Rights Act, The Americans with Disabilities Act (ADA), ORS 413.550 to 413.558, and subject to the requirements in OAR Chapter 950 Division 50. These services must be provided at no cost to the member. This rule applies to Fee-For-Service providers; for those contracting with a Coordinated Care Organization, refer to OAR 410-141-3515(12) or contact your contracted CCO for requirements.

(2) Enrolled OHP providers who wish to bill the Authority for Interpreter services when communicating with a patient who prefers to communicate in a language other than English, including signed languages:

(a) Shall work with a qualified or certified health care interpreter from the health care interpreter central registry administered by the Authority;

(b) Exceptions to working with the central registry interpreters are specified in OAR 950-050-0160;

(3) Documentation requirements: When OHP enrolled providers request reimbursement for interpreter services, the services must be included in the member record. This information can be in any area of the member records if it would be accessible later in the event of an audit or for other review purposes. Documentation shall include:

(a) The name of the health care interpreter;

(b) The health care interpreter's registry number;

(d) Date, time and duration of service.

(e) If not working with a Registry interpreter, documentation shall also include:

(A) A description of the attempts taken to use a Registry interpreter, and why these were not successful; or

(B) Documentation that the patient declined the Registry interpreter and chose a different interpreter.

(4) Coverage limitations:

(a) OHP will reimburse for interpreter services required for limited and non-English speaking members and/or deaf/hard of hearing members, when these services are necessary and reasonable to communicate effectively with members regarding health need;

(b) Interpreter services can only be covered in conjunction with another covered OHP service or medically necessary follow-up visit(s) to the initial covered service;

(c) OHP will not reimburse for family members or personal friends used as interpreters unless they are on the registry and doing so is appropriate under federal standards. For the purposes of this rule, "Family" means any of the following: husband or wife, natural or adoptive parent, child, or sibling, stepparent, stepchild, stepbrother or stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, grandparent or grandchild, spouse of grandparent or grandchild or any person sharing a common abode as part of a single-family unit;

(d) OHP will not reimburse for interpretation provided by doctors, clinicians or staff who are not listed on the registry or who are not proficient in the preferred language of the person consistent with nationally recognized professional standards of care as outlined by organizations such as the American Medical Association, the Joint Commission, the National Committee for Quality Assurance, or another equivalent national standard.

(5) Pursuit to OAR 410-120-1280 providers and provider entities are prohibited from billing the Medicaid member for the interpreter services or for the difference between submitted charges and the reimbursement amount. Providers are prohibited from using the Agreement to Pay form 3165 or 3166 to collect these charges to the OHP member.

(6) Providers ineligible for separate reimbursement. The Authority will not separately reimburse for interpreter services for the following provider types:

(a) Inpatient Hospitals-- included in the inpatient hospital DRG payment method;

(b) Federally Qualified Health Centers (FQHCs) - costs are included in the encounter rate;

(d) Indian Health Service (IHS) - costs are included in the encounter rate;

(e) Long-term care facilities - included in the per diem rate;

(f) Non-Emergency Medical Transportation providers - the service of transporting a patient does not include interpreter service reimbursements.

(g) Home Health Agencies- reimbursement based on Medicare cost report;

(h) Certified Community Behavioral Health Clinics (CCBHCs) - costs are included in the encounter rate;

(i) Residential Treatment Facilities and Residential Treatment Homes as defined in ORS 443.400 - included in the per diem rate;

(j) Authority Licensed Mental Health Adult Foster Homes as defined in ORS 443.705- included in the per diem rate;

(k) Hospice.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 46-2023, minor correction filed 06/05/2023, effective 06/05/2023
DMAP 55-2022, adopt filed 06/09/2022, effective 07/01/2022

Or. Admin. R. 410-120-0003 OHP Standard Benefit Package

The OHP Standard benefit package is eliminated effective January 1, 2014. Although references to OHP Standard exist elsewhere in rule, the benefit package currently is not funded and is not offered as a benefit. Those enrolled in OHP Standard are enrolled in other existing benefit packages.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.706
DAMP 74-2013, f. 12-31-13, cert. ef. 1-1-14

Or. Admin. R. 410-120-0006 Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedures consistent with applicable law. As outlined in OAR 943-001-0020, the Authority and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461 for all overpayment, personal injury liens, and estates administration for Authority programs covered under OAR chapter 410, division 200.

(2) Any reference to OAR chapter 461 in contracts of the Authority are deemed to be references to the requirements of this rule and shall be construed to apply to all eligibility policies, procedures, and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.065
DMAP 25-2019, amend filed 06/26/2019, effective 07/01/2019
DMAP 7-2019, amend filed 03/27/2019, effective 04/01/2019
DMAP 90-2018, amend filed 09/11/2018, effective 09/30/2018
DMAP 72-2018, amend filed 06/21/2018, effective 07/01/2018
DMAP 54-2017, amend filed 12/26/2017, effective 01/01/2018
DMAP 47-2017, temporary amend filed 11/07/2017, effective 11/07/2017 through 03/31/2018
DMAP 24-2017, f. 6-29-17, cert. ef. 7-1-17
DMAP 8-2017(Temp), f. & cert. ef. 3-1-17 thru 8-27-17
DMAP 58-2016, f. 9-30-16, cert. ef. 10-1-16
DMAP 46-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 32-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 70-2015, f. 12-8-15, cert. ef. 1-1-16
DMAP 49-2015, f. 9-3-15, cert. ef. 10-1-15
DMAP 33-2015, f. 6-24-15, cert. ef. 7-1-15
DMAP 12-2015(Temp), f. 3-5-15, cert. ef. 3-19-15 thru 9-14-15
DMAP 54-2014, f. & cert. ef. 9-23-14
DMAP 41-2014, f. & cert. ef. 7-1-14
DMAP 18-2014, f. 3-28-14, cert. ef. 3-31-14
DMAP 9-2014(Temp), f. 1-31-14, cert. ef. 2-1-14 thru 3-31-14
DMAP 59-2013(Temp), f. 10-31-13, cert. ef. 11-1-13 thru 3-31-14
DMAP 55-2013(Temp), f. & cert. ef. 10-2-13 thru 3-31-14
DMAP 52-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14
DMAP 51-2013, f. & cert. ef. 10-1-13
DMAP 44-2013(Temp), f. 8-21-13, cert. ef. 8-23-13 thru 1-28-14
DMAP 39-2013(Temp), f. 7-26-13, cert. ef. 8-1-13 thru 1-28-14
DMAP 32-2013, f. & cert. ef. 6-27-13
DMAP 24-2013, f. & cert. ef. 5-29-13
DMAP 17-2013, f. & cert. ef. 4-10-13
DMAP 12-2013, f. 3-27-13, cert. ef. 4-1-13
DMAP 7-2013(Temp), f. & cert. ef. 3-1-13 thru 6-29-13
DMAP 5-2013(Temp), f. & cert. ef. 2-20-13 thru 6-29-13
DMAP 3-2013(Temp), f. & cert. ef. 1-30-13 thru 6-29-13
DMAP 2-2013(Temp), f. & cert. ef. 1-8-13 thru 6-29-13
DMAP 65-2012(Temp), f. 12-28-12, cert. ef. 1-1-13 thru 6-29-13
DMAP 60-2012, f. 12-27-12, cert. ef. 1-1-13
DMAP 56-2012(Temp), f. 11-30-12, cert. ef. 12-1-12 thru 4-1-13
DMAP 53-2012(Temp), f. & cert. ef. 11-1-12 thru 4-29-13
DMAP 50-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 45-2012(Temp), f. & cert. ef. 10-5-12 thru 1-19-13
DMAP 35-2012(Temp), f. & cert. ef. 7-20-12 thru 1-15-13
DMAP 25-2012(Temp), f. & cert. ef. 5-1-12 thru 7-10-12
DMAP 21-2012(Temp), f. 3-30-12, cert. ef. 4-1-12 thru 7-10-12
DMAP 9-2012(Temp), f. & cert. ef. 3-1-12 thru 7-10-12
DMAP 4-2012(Temp), f. 1-31-12, cert. ef. 2-1-12 thru 7-10-12
DMAP 3-2012(Temp), f. & cert. ef. 1-31-12 thru 2-1-12
DMAP 2-2012(Temp), f. & cert. ef. 1-26-12 thru 7-10-12
DMAP 1-2012(Temp), f. & cert. e.f 1-13-12 thru 7-10-12
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 25-2011(Temp), f. 9-28-11, cert. ef. 10-1-11 thru 1-11-12
DMAP 21-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-11-12
DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12
DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11

Or. Admin. R. 410-120-0025 Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence

(1) The Oregon Health Authority (Authority) and its Division of Medical Assistance Programs (Division) may adopt reasonable and lawful policies, procedures, rules, and interpretations to promote the orderly and efficient administration of medical assistance programs including the Oregon Health Plan pursuant to ORS 414.065 (generally, fee-for-service), 414.591 (Coordinated Care Organizations), and 414.115 to 414.145 (services contracts), subject to the rulemaking requirements of the Oregon Revised Statutes and Oregon Administrative Rule (OAR) procedures.

(2) In applying its policies, procedures, rules, and interpretations, the Division shall construe them as much as possible to be complementary. In the event that Division policies, procedures, rules and interpretations may not be complementary, the Division shall apply the following order of precedence to guide its interpretation:

(a) For purposes of the provision of covered medical assistance to Division clients, including but not limited to authorization and delivery of service or denials of authorization or services, the Division, clients, enrolled providers, Coordinated Care Organizations, and the Prepaid Health Plans shall apply the following order of precedence:

(A) Oregon Revised Statutes governing medical assistance programs;

(B) Consistent with ORS 413.071, those federal laws and regulations governing the operation of the medical assistance program and any waivers granted the Authority by the Centers for Medicare and Medicaid Services to operate medical assistance programs including the Oregon Health Plan;

(C) Generally for Coordinated Care Organizations, the requirements applicable to the providing covered medical assistance to Division clients are found in OAR 410-141-3500 through 410-141-5380; and where applicable, 410-120-0000 through 410-120-1990; and the provider rules applicable to the category of medical service;

(D) Generally for Prepaid Health Plans, the requirements applicable to providing covered medical assistance to Division clients are found in OAR 410-141-3500 through 410-141-5380; and where applicable, 410-120-0000 through 410-120-1990; and the provider rules applicable to the category of medical service;

(E) Generally for enrolled fee-for-service providers or other contractors, the requirements applicable to providing covered medical assistance to Division clients are found in OAR 410-120-0000 through 410-120-1990, the Prioritized List and program coverage set forth in 410-141-3820 to 410-141-3830, and the provider rules applicable to the category of medical service;

(F) Any other applicable duly promulgated rules issued by the Division and other offices or units within the Authority or Department of Human Services necessary to administer the State of Oregon’s medical assistance programs, such as electronic data transaction rules in OAR 943-120-0100 to 943-120-0200; and

(G) The basic framework for provider enrollment in OAR 943-120-0300 through 943-120-0380 that generally apply to providers enrolled with the Authority or Department, subject to more specific requirements applicable to the administration of the Oregon Health Plan and medical assistance programs administered by the Authority. For purposes of this rule, “more specific” means the requirements, laws and rules applicable to the provider type and covered services described in paragraphs (A)–(F) of this section of this rule.

(b) For purposes of contract administration solely as between the Authority and its Coordinated Care Organizations or Prepaid Health Plans, the terms of the applicable contract and the requirements in section (2)(a) of this rule apply to the provision of covered medical assistance to Division clients:

(A) Nothing in this rule shall be deemed to incorporate into contracts provisions of law not expressly incorporated into such contracts, nor shall this rule be deemed to supersede any rules of construction of such contracts that may be provided for in such contracts;

(B) Nothing in this rule gives, is intended to give, or shall be construed to give or provide any benefit or right, whether directly or indirectly or otherwise, to any individual or entity unless the individual or entity is identified as a named party to the contract.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 15-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 48-2022, minor correction filed 04/21/2022, effective 04/21/2022
DMAP 40-2015, f. & cert. ef. 7-1-15
DMAP 48-2013, f. & cert. ef. 9-12-13
DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
DMAP 11-2008, f. 4-29-08, cert. ef. 5-1-08
DMAP 6-2008(Temp), f. & cert. ef. 3-14-08 thru 9-1-08
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05

Or. Admin. R. 410-120-0030 Children’s Health Insurance Program

(1) The Children’s Health Insurance Program (CHIP) is a federal non-entitlement program. The Oregon Health Authority (Authority), Division of Medical Assistance Program (Division) administers two programs funded under CHIP in accordance with the Oregon Health Plan (OHP) waiver and the CHIP state plan:

(a) CHIP: Provides health coverage for uninsured, low-income children who are ineligible for Medicaid;

(b) CHIP Pre-natal care expansion program.

(2) The General Rules Program (OAR 410-120-0000 et. seq.) and the OHP Program rules (OAR 410-141-3500 et. seq.) applicable to the Medicaid program are also applicable to the Authority’s CHIP program.

(3) Children under 19 years of age who meet the income limits, citizenship requirements and eligibility criteria for medical assistance established in OAR chapter 410 through the program acronym OHP-CHP receive the OHP benefit package. (For benefits refer to OAR 410-120-1210.)

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 16-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 67-2013, f. & cert. ef. 12-3-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 19-2012, f. 3-30-12, cert. ef. 4-1-12
DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 23-2010, f. & cert. ef. 9-1-10
DMAP 23-2010, f. & cert. ef. 9-1-10
DMAP 18-2010, f. 6-23-10, cert. ef. 7-1-10
DMAP 37-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 29-2009(Temp), f. 9-15-09, cert. ef. 10-1-09 thru 3-25-10
DMAP 14-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 7-2008(Temp), f. 3-17-08 & cert. ef. 4-1-08 thru 9-15-08

Or. Admin. R. 410-120-0035 Public Entity

(1) This rule pertains to Centers for Medicare and Medicaid (CMS) regulations for payments to and from Oregon Health Authority (Authority) and public entities.

(2) Effective July 1, 2008, unit of government providers responsible by rule or contract for the local match share portion for claims eligible for Federal Financial Participation (FFP) submitted to Medicaid for reimbursement must submit the local match payment prior to the Authority claiming the federal share from CMS:

(a) Before the provider submits its claims to the Authority, the provider must transfer funds from allowable sources to the Authority representing the local match share of the total allowable cost for claimed services;

(b) Upon receipt of provider’s transfer of the local match share and the Authority receipt of claims in the Medical Management Information System (MMIS) that are reimbursable to the extent of the transferred local match share amount, the Authority will claim FFP from CMS and reimburse the provider for the total reimbursable allowable claimed amount for the services;

(c) Transfer of the local match share to the Authority means that the provider certifies that for the purposes of 42 CFR 433.51, the funds it transfers to the Authority for the local match share are public funds that are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds; and that all sources of funds are allowable under 42 CFR 433 Subpart B.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 30-2008, f. 9-12-08, cert. ef. 9-15-08
DMAP 27-2008(Temp), f. 6-13-08, cert. ef. 7-1-08 thru 12-28-08

Or. Admin. R. 410-120-0045 Applications for Medical Assistance at Provider Locations

(1) The Oregon Health Authority (Authority) allows Division enrolled providers the opportunity to assist applicants applying for public and private health coverage offered through the Authority and the Oregon Health Insurance Exchange (OHIX, as defined in ORS 741.300(6)). To apply for this opportunity, providers fill out and submit form OHA 3128, Application Assistance by Provider Staff or “addendum”; this is an addendum to the provider’s agreement to provide Medicaid reimbursed services. Once the provider is determined certified by the Oregon Health Authority to provide application assistance, providers shall receive an approval letter, requirements for assister certification, training requirements, and other information.

(2) For purposes of this rule, the provider’s practice shall be referred to as a site. Sites can be, but are not limited to, the following:

(a) Hospitals;

(b) Federally qualified health centers/rural health clinics (FQHC/RHCs);

(d) Substance Use Disorder adult and adolescent treatment and recovery centers;

(e) Tribal health clinics;

(f) Family Planning clinics;

(g) Other primary care clinics as approved by the Oregon Health Authority.

(3) The site may sign the “Application Assistance by Provider Staff Form” (OHA 3128) or “the addendum” indicating the site’s willingness to provide application assistance. The addendum outlines site and application assister standards as well as conflict of interest protections. The site shall require employees that are assisting to participate in mandatory training sessions for application assistance certification. Employees and volunteers shall complete the certification process before initiating application assistance. Sites shall ensure that individuals performing application assistance are recertified at appropriate times as set forth by the Oregon Health Authority. For purposes of this rule, certified staff shall be referred to as “application assisters.”

(4) Application assisters shall utilize authorized methods to provide application assistance. Application assisters shall maintain copies of all eligibility verification documents and all records related to application assistance, including the required, current OHA-provided 6610 Form for six (6) years, whether in paper, electronic, or other forms in a secure and locked location. Application assisters support patients potentially eligible for public and private health coverage offered through the Authority and OHIX.

(5) The application assister shall encourage applicants to provide accurate and truthful information, assist in completing the application and enrollment process, and shall assure that the information contained on the application is complete. The application assister may not attempt to pre-determine applicant eligibility or make any assurances to an applicant regarding the eligibility for public or private health coverage offered through the Oregon Health Authority and OHIX.

(6) The application assister shall provide information to applicants about public medical programs and plans through OHIX so each applicant can make an informed choice when enrolling into a health insurance product. The application assister must offer language interpreters or interpreter services or referrals before beginning an application and must provide a language interpreter or interpretive services or referral to all patients who accept. This must also include linguistically and culturally appropriate written materials:

(a) The information given to the applicant shall, at a minimum:

(A) Include a review of public medical programs and qualified health plans through OHIX;

(B) Provide unbiased health coverage choices and information provided by the Oregon Health Authority or OHIX during the enrollment process;

(D) and assist in filling out online or paper application forms.

(b) The application assister shall make copies of the original eligibility verification documentation required to accompany the application, but not uploaded to ONE applicant portal.

(7) Providers, staff, contracted employees, and volunteers are subject to all applicable provisions under General Rules OAR Chapter 410, Division 120, and Application Assistance by Provider Staff addendum (OHP 3128):

(a) The application assister shall treat all information they obtain for public medical programs and OHIX as confidential and privileged communications. The application assister may not disclose such information without the written consent of the individual, their delegated authority, attorney, or responsible parent of a minor child or child’s guardian.

(b) The Oregon Health Authority, Oregon Department of Human Services and sites shall share information as necessary to effectively serve public medical programs and OHIX eligible or potentially eligible individuals;

(c) Personally identifiable health information about applicants and recipients shall be subject to the transaction, security, and privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA) and the administrative rules there under. Sites shall cooperate with the Authority in the adoption of policies and procedures for maintaining the privacy and security of records and for conducting transactions pursuant to HIPAA requirements.

(8) The Oregon Health Authority shall be responsible for the following:

(a) The Oregon Health Authority shall provide training to application assisters on public medical programs and OHIX, eligibility and enrollment, application procedures, and documentation requirements. The Authority shall set dates and times for these additional training classes as needed, following changes in policy or procedure;

(b) The Authority shall make available public medical programs application forms online and in hard copy (in English, translated languages, and alternative formats), and health insurance coverage options ;

(c) The Oregon Authority and Oregon Department of Human Services shall process all applications in accordance with Authority and OHIX standards;

(d) The Authority shall process completed applications within the time requirements in the Authority and OHIX policy. In the event of a change in policy, the time for completion of processing shall be changed to the new time requirements.

(9) The Oregon Health Authority shall provide all necessary forms and applications as referenced above at no cost to the site. There are no monetary provisions in this rule for any payment for the performance of work by the site, except for those costs provided under OAR 410-147-0400 and 410-146-0460, because there is compensation for Out stationed Outreach Worker (OSOW) activities outlined in OAR 410-147-0400 for FQHCs and RHCs and OAR 410-146-0460 for Indian Health Care Providers (IHCPs). The Authority does not guarantee a particular volume of business under these rules.

(10) The provider may terminate enrollment at any time as outlined in OAR 410-120-1260(15).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.041
DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024
DMAP 93-2024, amend filed 05/24/2024, effective 05/24/2024
DMAP 17-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 52-2016, f. 8-26-16, cert. ef. 9-1-16
DMAP 71-2013, f. & cert. ef. 12-27-13
DMAP 48-2013, f. & cert. ef. 9-12-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 12-2010, f. 6-10-10, cert. ef. 7-1-10

Or. Admin. R. 410-120-0250 Managed Care Entity

(1) The Authority provides clients with health services through contracts with a Managed Care Entity (MCE).

(2) The MCE is responsible for providing, arranging, and making reimbursement arrangements for covered services as governed by state and federal law, or MCE's contract with the Authority, and the OHP administrative rules governing MCEs (OAR chapter 410, division 141).

(3) All MCEs are required to provide benefit coverage pursuant to OAR 410-120-1210 and 410-141-0480 through 410-141-0520; however, authorization criteria may vary between MCEs. It is the providers' responsibility to comply with the MCE's Prior Authorization requirements or other policies necessary for reimbursement from the MCE before providing services to any OHP client enrolled in an MCE.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065, 414.631 & 414.651
DMAP 76-2022, minor correction filed 09/30/2022, effective 09/30/2022
DMAP 62-2017, amend filed 12/28/2017, effective 01/01/2018
DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
OMAP 67-2005, f. 12-21-05, cert. ef. 1-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03

Or. Admin. R. 410-120-1140 Verification of Eligibility and Coverage

(1) To ensure Division reimbursement of services, providers are responsible to verify the following before rendering services:

(a) Client eligibility: That the person is an eligible Oregon Health Plan (OHP) client on the date(s) services are rendered; and

(b) Benefit coverage: That the person is enrolled in an OHP benefit package that covers the services they plan to render. See OAR 410-120-1210 for services covered under each Division benefit package.

(2) Providers who do not verify eligibility and benefit coverage with the Division before serving a person shall assume full financial responsibility in serving that person.

(3) The following types of client identification (ID) only list the client’s name, Oregon Medicaid ID number (prime number), and the date the ID was issued. They do not guarantee client eligibility or benefit coverage:

(a) The standard ID (called the Oregon Health ID, formerly the DHS Medical Care ID) printed on perforated paper the size of a business card;

(b) Replacement IDs (printed on regular printer paper in case of misplaced originals).

(4) When a person presents a standard or replacement ID, providers must verify client eligibility and benefit coverage through one of the following (For instructions see the Division General Rules Supplemental Information available on the web at http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-General-Rules.aspx:

(a) The Division’s Medicaid Management Information System (MMIS) Provider Web portal;

(b) The Automated Voice Response (AVR) telephone system;

(5) The client may also present the Temporary Oregon Health ID: OHP 3263A: Approval Notice for Hospital Presumptive Eligibility for Medical Coverage: This ID is issued for those who are “presumed” eligible based on certain information and authorizes benefit coverage only on a temporary basis. The OHP 3263A informs the client of the exact date by which the Division must receive their full Medicaid application so that they may be evaluated for ongoing eligibility.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065, 414.025 & 411.400
DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023
DMAP 31-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 42-2014, f. & cert. ef. 7-3-14
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 10-1999, f. & cert. ef. 4-1-99, Renumbered from 410-120-0080
HR 32-1993, f. & cert. ef. 11-1-93
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 41-1991, f. & cert. ef. 10-1-91
HR 25-1991(Temp), f. & cert. ef. 7-1-91, Renumbered from 461-013-0103 & 461-013-0109
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0040
AFS 53-1988(Temp), f. 8-23-88, cert. ef. 9-1-88
AFS 53-1987, f. 10-29-87, cert. ef. 11-1-87
AFS 10-1987, f. 2-27-87, cert. ef. 3-1-87
AFS 78-1986(Temp), f. 12-16-86, cert. ef. 1-1-87
AFS 57-1986, f. 7-25-86, cert. ef. 8-1-86
AFS 43-1986(Temp), f. 6-13-86, cert. ef. 7-1-86
AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85
AFS 61-1983, f. 12-19-83, cert. ef. 1-1-84
AFS 103-1982, f. & cert. ef. 11-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 14-1979, f. 6-29-79, cert. ef. 7-1-79
AFS 14-1979, f. 6-29-79, cert. ef. 7-1-79
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1160 Medical Assistance Benefits and Provider Rules

(1) Providers enrolled with and seeking reimbursement for services through the Health Systems Division (Division) are responsible for compliance with current federal and state laws and regulations governing Medicaid services and reimbursement, including familiarity with periodic law and rule changes. The Division’s administrative rules are posted on the Oregon Health Authority (Authority) website for the Division and its medical assistance programs. It is the provider's responsibility to become familiar with and abide by these rules.

(2) The following services are covered to the extent included in the Division client's benefit package of health care services, when medically or dentally appropriate and within the limitations established by the Division and set forth in the Oregon Administrative Rules (OARs) for each category of Health Services:

(a) Acupuncture services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(b) Administrative examinations as described in the Administrative Examinations and Billing Services program provider rules (OAR chapter 410, division 150);

(A) The Division covers Substance Use Disorder (SUD) inpatient treatment services for medically managed intensive inpatient detoxification when provided in an acute care hospital and when hospitalization is considered medically appropriate. The Division covers medically monitored detoxification and clinically managed detoxification provided in a free standing detoxification center or an appropriately licensed SUDs residential treatment facility when considered medically appropriate;

(B) The Division covers non-hospital SUD treatment and recovery services on a residential or outpatient basis. For information to access these services, contact the client's PHP or CCO if enrolled, the Community Mental Health Program (CMHP), an outpatient substance use disorder treatment provider, the residential treatment program, or the Addictions and Mental Health Division (AMH);

(C) The Division does not cover residential level of care provided in an inpatient hospital setting for substance use disorder treatment and recovery;

(d) Ambulatory surgical center services as described in the Medical-Surgical Services program provider rules (OAR 410, division 130);

(e) Anesthesia services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(f) Audiology services as described in the Speech-Language Pathology, Audiology and Hearing Aid Services program provider rules (OAR chapter 410, division 129);

(g) Chiropractic services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(h) Clinical trials as described in these General Rules:

(A) Coverage includes routine patient costs for a beneficiary participating in a qualifying clinical trial or any item or service provided to the individual under the qualifying clinical trial, including any item or service provided to prevent, diagnose, monitor, or treat complications resulting from participation in the qualifying clinical trial, to the extent that the items or services to the beneficiary are covered in the recipient’s benefit package;

(B) “Qualifying clinical trial” is defined as a clinical trial in any clinical phase of development that is conducted in relation to the prevention, detection, or treatment of any serious or life-threatening disease or condition as described in section 1905(gg)(2)(A) of the Act;

(C) A qualifying clinical trial is a study or investigation that is approved, conducted, or supported (including by funding through in-kind contributions) by one or more of the following:

(i) The National Institutes of Health (NIH);

(ii) The Centers for Disease Control and Prevention (CDC);

(iii) The Agency for Health Care Research and Quality (AHRQ);

(iv) The Centers for Medicare & Medicaid Services (CMS);

(v) A cooperative group or center of any of the entities described above or the Department of Defense or the Department of Veterans Affairs;

(vi) A qualified non-governmental research entity identified in the guidelines issued by the NIH for center support grants;

(vii) A clinical trial, approved or funded by any of the following entities, that has been reviewed and approved through a system of peer review that the Secretary determines comparable to the system of peer review of studies and investigations used by the NIH, and that assures unbiased review of the highest scientific standards by qualified individuals with no interest in the outcome of the review:

(I) The Department of Energy;

(II) The Department of Veterans Affairs;

(III) The Department of Defense;

(viii) A clinical trial that is one conducted pursuant to an investigational new drug exemption under section 505(i) of the Federal Food, Drug, and Cosmetic Act or an exemption for a biological product undergoing investigation under section 351(a)(3) of the Public Health Service Act; or

(ix) A clinical trial that is a drug trial exempt from being required to have one of the exemptions in the prior bullet.

(D) Items and Services not included in clinical trial:

(i) Routine patient costs do not include any investigational item or service that is the subject of the qualifying clinical trial but is not included in the recipient’s OHP benefit package;

(ii) Routine patient cost does not include any item or service that is provided to the beneficiary solely to satisfy data collection and analysis for the qualifying clinical trial that is not used in the direct clinical management of the beneficiary and is not otherwise in the recipients OHP benefit package.

(i) Dental services as described in the Dental Services program provider rules (OAR chapter 410, division 123);

(j) Early and Periodic Screening, Diagnosis, and Treatment services (EPSDT) are covered for individuals under 21 years of age as set forth in the individual program provider rules. The Division may authorize services in excess of limitations established in the OARs when it is medically appropriate to treat a condition that is identified as the result of an EPSDT screening;

(k) Family planning services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(l) Federally qualified health centers and rural health clinics as described in the Federally Qualified Health Centers and Rural Health Clinics program provider rules (OAR chapter 410, division 147);

(m) Home and community-based waiver services as described in the Authority and the Department’s OARs of Child Welfare (CW), Self-Sufficiency Program (SSP), Addictions and Mental Health Division (AMH), and Aging and People with Disabilities Division (APD);

(n) Home enteral/parenteral nutrition and IV services as described in the Home Enteral/Parenteral Nutrition and IV Services program rules (OAR chapter 410, division 148) and related Durable Medical Equipment. Prosthetics, Orthotics and Supplies program rules (OAR chapter 410, division 122) and Pharmaceutical Services program rules (OAR chapter 410, division 121);

(o) Home health services as described in the Home Health Services program rules (OAR chapter 410, division 127);

(p) Hospice services as described in the Hospice Services program rules (OAR chapter 410, division 142);

(q) HRSN Services as described in the HRSN Services program rules (OAR 410-120-2000);

(r) Indian health services or tribal facility as described in The Indian Health Care Improvement Act and its amendments (Public Law 102-573), and the Division’s American Indian/Alaska Native program rules (OAR chapter 410, division 146);

(s) Inpatient hospital services as described in the Hospital Services program rules (OAR chapter 410, division 125);

(t) Laboratory services as described in the Hospital Services program rules (OAR chapter 410, division 125) and the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(u) Licensed direct-entry midwife services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(v) Maternity case management as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(w) Medical equipment and supplies as described in the Hospital Services program, Medical-Surgical Services program, DMEPOS program, Home Health Services program, Home Enteral/Parenteral Nutrition and IV Services program, and other rules;

(x) When a client's benefit package includes mental health, the mental health services provided shall be based on the Health Evidence Review Commission (HERC) Prioritized List of Health Services;

(y) Naturopathic services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(z) Nutritional counseling as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(aa) Occupational therapy as described in the Physical and Occupational Therapy Services program rules (OAR chapter 410, division 131);

(bb) Organ transplant services as described in the Transplant Services program rules (OAR chapter 410, division 124);

(cc) Outpatient hospital services including clinic services, emergency department services, physical and occupational therapy services, and any other outpatient hospital services provided by and in a hospital as described in the Hospital Services program rules (OAR chapter 410, division 125);

(dd) Physician, podiatrist, nurse practitioner and licensed physician associate services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(ee) Physical therapy as described in the Physical and Occupational Therapy and the Hospital Services program rules (OAR chapter 410, division 131 and 125);

(ff) Post-hospital extended care benefit as described in OAR chapter 410, division 120, 141 and OAR chapter 411, division 070, Aging and People with Disabilities (APD) program rules;

(gg) Prescription drugs including home enteral and parenteral nutritional services and home intravenous services as described in the Pharmaceutical Services program (OAR chapter 410, division 121), the Home Enteral/Parenteral Nutrition and IV Services program (OAR chapter 410, division 148), and the Hospital Services program rules (OAR chapter 410, division 125);

(hh) Preventive services as described in the Medical-Surgical Services program (OAR chapter 410, division 130), the Dental Services program rules (OAR chapter 410, division 123), and prevention guidelines associated with the Health Evidence Review Commission's Prioritized List of Health Services (OAR 410-141-0520);

(ii) Private duty nursing as described in the Private Duty Nursing Services program rules (OAR chapter 410, division 132);

(jj) Radiology and imaging services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130), the Hospital Services program rules (OAR chapter 410, division 125), and Dental Services program rules (OAR chapter 410, division 123);

(kk) Rural health clinic services as described in the Federally Qualified Health Center and Rural Health Clinic Program rules (OAR chapter 410, division 147);

(ll) School-based health services as described in the School-Based Health Services Program rules (OAR chapter 410, division 133);

(mm) Speech and language therapy as described in the Speech-Language Pathology, Audiology and Hearing Aid Services program rules (OAR chapter 410, division 129) and Hospital Services program rules (OAR chapter 410, division 125);

(nn) Transportation necessary to access a covered medical service or item as described in the Medical Transportation program rules (OAR chapter 410, division 136);

(oo) Vision services as described in the Visual Services program rules (OAR chapter 410, division 140).

(3) Other Authority or Department, divisions, units, or offices, including Vocational Rehabilitation, AMH, and APD may offer services to Medicaid eligible clients, that are not reimbursed by or available through the Division of Medical Assistance Programs.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & SB 269-b (2025)
DMAP 86-2025, amend filed 12/05/2025, effective 01/01/2026
DMAP 3-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 18-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 86-2022, amend filed 11/30/2022, effective 12/01/2022
DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14
DMAP 71-2013, f. & cert. ef. 12-27-13
Reverted to DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru 12-24-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04
OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 31-1999, f. & cert. ef. 10-1-99
OMAP 10-1999, f. & cert. ef. 4-1-99
HR 21-1997, f. & cert. ef. 10-1-97
HR 40-1994, f. 12-30-94, cert. ef. 1-1-95
HR 2-1994, f. & cert. ef. 2-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0440
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 33-1992, f. 10-30-92, cert. ef. 11-1-92
HR 27-1992(Temp), f. & cert. ef. 9-1-92
HR 41-1991, f. & cert. ef. 10-1-91
HR 32-1990, f. 9-24-90, cert. ef. 10-1-90
HR 19-1990, f. & cert. ef. 7-9-90
HR 5-1990(Temp), f. 3-30-90, cert. ef. 4-1-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0102
AFS 47-1989, f. & cert. ef. 8-24-89
AFS 14-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 8-1989(Temp), f. 2-24-89, cert. ef. 3-1-89
AFS 4-1989, f. 1-31-89, cert. ef. 2-1-89
AFS 70-1988, f. & cert. ef. 12-7-88
AFS 69-1988, f. & cert. ef. 12-5-88
AFS 58-1988(Temp), f. & cert. ef. 9-27-88
AFS 51-1988(Temp), f. & cert. ef. 8-2-88
AFS 6-1988, f. & cert. ef. 2-1-88
AFS 32-1987, f. 7-22-87, ef. 8-1-87
AFS 17-1987, f. 5-4-87, ef. 6-1-87
AFS 16-1987(Temp), f. & ef. 4-1-87
AFS 76-1986(Temp), f. & ef. 12-8-86
AFS 67-1986(Temp), f. 9-26-86, ef. 10-1-86
AFS 53-1985, f. 9-20-85, ef. 10-1-85
AFS 14-1985, f. 3-14-85, ef. 4-1-85
AFS 25-1984, f. 6-8-84, ef. 7-1-84
AFS 12-1984, f. 3-16-84, ef. 4-1-84
AFS 4-1984, f. & ef. 2-1-84
AFS 62-1983, f. 12-19-83, ef. 1-1-84
AFS 42-1983, f. 9-2-83, ef. 10-1-83
AFS 117-1982, f. 12-30-82, ef. 1-1-83
AFS 103-1982, f. & ef. 11-1-82
AFS 94-1982(Temp), f. & ef. 10-18-82
AFS 52-1982, f. 5-28-82, ef. 6-30-82
Renumbered from 461-013-0000, AFS 47-1982, f. 4-30-82, ef. 5-1-82
AFS 71-1981, f. 9-30-81, ef. 10-1-81
AFS 5-1981, f. 1-23-81, ef. 3-1-81
AFS 73-1980(Temp), f. & ef. 10-1-80
AFS 14-1979, f. 6-29-79, ef. 7-1-79
PWC 812, f. & ef. 10-1-76
PWC 803(Temp), f. & ef. 7-1-76
PWC 683, f. 7-19-74, ef. 8-11-74

Or. Admin. R. 410-120-1180 Medical Assistance Benefits: Out-of-State Services

(1) A provider located in a state other than Oregon whose services are rendered in that state shall be licensed and otherwise certified by the proper agencies in the state of residence as qualified to render the services. Certain cities within 75 miles of the Oregon border may be closer for Oregon residents than major cities in Oregon, and therefore, these areas are considered contiguous areas, and providers are treated as providing in-state services.

(2) Out-of-state providers must enroll with the Authority as described in OARs 943-120-0320 and 410-120-1260, Provider Enrollment. Out-of-state providers must provide services and bill in compliance with these rules and the OARs for the appropriate type of services provided.

(3) Payment rates for out-of-state providers are established in the individual provider rules through contracts or service agreements and in accordance with OAR chapter 943, division 120 and OAR 410-120-1340, Payment.

(4) For enrolled non-contiguous, out-of-state providers, the Division reimburses for covered services under any of the following conditions:

(a) For clients enrolled in an MCE:

(A) The service is authorized by an MCE, and payment to the out-of-state provider is the responsibility of the MCE;

(B) If a client has coverage through an MCE, the request for non-emergency services must be referred to the MCE. Payment for these services is the responsibility of the MCE;

(C) The service or item is not available in the State of Oregon or provision of the service or item by an out-of-state provider is cost effective, as determined by the MCE.

(D) MCE must provide all Members with the option to utilize mail order pharmacy services. MCE may use an out-of-state mail order provider when necessary to meet the needs of the Member, as long as the pharmacy has signed a participating provider agreement or subcontract with the MCE, is licensed to operate in state they reside, and adheres to out-of-state services and other applicable Division rules.

(b) For clients not enrolled in an MCE:

(A) The service to a Division client is emergent as defined in 410-120-0000;

(B) A delay in the provision of services until the client is able to return to Oregon could reasonably be expected to result in prolonged impairment, or in increased risk that treatment will become more complex or hazardous, or in substantially increased risk of the development of chronic illness;

(C) The Division authorized payment for the service in advance of the provision of services or is otherwise authorized in accordance with payment authorization requirements in the individual provider rules or in the General Rules;

(D) The service is being billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance coverage;

(E) The client is traveling and unable to use an in-state pharmacy;

(F) The pharmacy is out-of-state and mail order; the primary insurance TPL policy requires the use of the pharmacy;

(G) The pharmacy is out-of-state and mail order and provides one or more pharmaceutical products that are only available through a limited distribution network.

(5) The Authority may give prior authorization (PA) for non-emergency out-of-state services provided by a non-contiguous enrolled provider under the following conditions:

(a) The service is billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance coverage; or

(b) The Division covers the service or item under the specific client's benefit package; and

(c) The service or item is not available in the State of Oregon, or provision of the service or item by an out-of-state provider is cost effective, as determined by the Division; and

(d) The service or item is deemed medically appropriate and is recommended by a referring Oregon physician.

(6) Laboratory analysis of specimens sent to out-of-state independent or hospital-based laboratories is a covered service and does not require PA. The laboratory must meet the same certification requirements as Oregon laboratories and must bill in accordance with Division rules.

(7) Reimbursement and services outside the territorial limits of the United states:

(a) For purposes of this provision, the United States includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa;

(b) The division may not provide any payments for items or services to any financial institution or entity located outside of the United States pursuant to 1902(a)(80) of the Social Security Act.

(A) This provision also prohibits payments to telemedicine providers and pharmacies located outside of the United States;

(B) This does not preclude providers from providing covered items and/or services to Medicaid beneficiaries provided that reimbursement is made to a financial institution or entities located within the United States.

(8) The Division shall reimburse within limits described in these General Rules and in individual provider rules all services provided by enrolled providers to children:

(a) Who the Division has placed in foster care;

(b) Who the Department has placed in a subsidized adoption outside the State of Oregon; or

(9) The Division does not require authorization of non-emergency services for the children covered by section (8) except as specified in the individual provider rules.

(10) Payment rates for out-of-state providers are established in the individual provider rules through contracts or service agreements and in accordance with OAR 943-120-0350 and 410-120-1340, Payment.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065 & 414.025
DMAP 84-2023, amend filed 11/30/2023, effective 12/01/2023
DMAP 78-2018, amend filed 06/27/2018, effective 07/01/2018
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 10-1999, f. & cert. ef. 4-1-99
OMAP 20-1998, f. & cert. ef. 7-1-98
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 40-1994, f. 12-30-94, cert. ef. 1-1-95
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0120, 410-120-0140 & 410-120-0160
HR 41-1991, f. & cert. ef. 10-1-91
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0045 & 461-013-0046
AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85
AFS 21-1985, f. 4-2-85, cert. ef. 5-1-85
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 33-1981, f. 6-23-81, cert. ef. 7-1-81; Renumbered from 461-013-0130
AFS 39-1978, f. 10-10-78, cert. ef. 11-1-78
AFS 27-1978(Temp), f. 6-30-78, cert. ef. 7-1-78
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-7

Or. Admin. R. 410-120-1190 Medically Needy Benefit Program

The Medically Needy Program is eliminated effective February 1, 2003. Although references to this benefit exist elsewhere in rule, the program currently is not funded and is not offered as a benefit.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
OMAP 2-2003, f. 1-31-03, cert. ef. 2-1-03

Or. Admin. R. 410-120-1200 Excluded Services and Limitations

(1) Certain services or items are not covered under any program or for any group of eligible clients. Service limitations are subject to either:

(a) the Health Evidence Review Commission (HERC) Prioritized List of Health Services as referenced in Oregon Administrative Rule (OAR) 410-141-3830 and the individual program chapter 410 OARs; or

(b) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in chapter 410 Division 151.

(2) If the client accepts financial responsibility for a non-covered service, payment is a matter between the provider and the client subject to the requirements of OAR 410-120-1280.

(3) The Health Systems Division (Division) shall make no payment for any expense incurred for services or items that meet any of the following:

(a) Determined not medically or dentally appropriate by Division staff or authorized representatives, including the Division's contracted utilization review organization, or are not covered by the Health Evidence Review Commission Prioritized List of Health Services;

(b) Not properly prescribed as required by law or administrative rule by a licensed practitioner practicing within their scope of practice or licensure;

(c) For routine checkups or examinations for individuals age 21 or older in connection with participation, enrollment, or attendance in an extracurricular program or activity not related to the improvement of health and rehabilitation of the client. Examples include routine drug test used for employment or exams for employment, or life insurance exams; (3)(c) of this rule is not for vaccines, for vaccine eligible coverage see OAR 410-130-0255.

(d) Provided by friends or relatives of eligible clients or members of his or her household, except when the friend, relative or household member:

(A) Is a health professional acting in a professional capacity; or

(B) Is directly employed by the client under the Department of Human Services (Department) Aging and People with Disabilities division (APD) Home and Community Based Services or the APD administrative rules, OAR 411-034-0000 through 411-034-0090, governing Personal Care Services covered by the State Plan; or

(C) Is directly employed by the client under the Department Child Welfare administrative rules, OAR 413-090-0100 through 413-090-0220, for services to children in the care and custody of the Department who have special needs inconsistent with their ages. A family member of a minor client (under the age of 18) must not be legally responsible for the client in order to be a provider of personal care services;

(e) For services or items provided to a client who is in the custody of a law enforcement agency or an inmate of a non-medical public institution, including juveniles in detention facilities, except such services as designated by federal statute or regulation as permissible for coverage under the Division’s administrative rules (i.e., inpatient hospitalizations);

(f) Needed for purchase, repair, or replacement of materials or equipment caused by adverse actions of adult clients age 21 and over to personally owned goods or equipment or to items or equipment that the Division rented or purchased;

(g) Related to a non-covered service, some exceptions are identified in the individual provider rules. If the Division determines the provision of a service related to a non-covered service is cost effective, the related medical service may, at the discretion of the Division and with Division prior authorization (PA), be covered;

(h) Considered experimental or investigational, that deviates from acceptable and customary standards of medical practice or for which there is insufficient outcome data to indicate efficacy;

(i) Identified in the appropriate program rules including the Division’s Hospital Services program administrative rules, Revenue Codes Section, as non-covered services;

(j) Requested by or for a client whom the Division has determined to be non-compliant with treatment and who is unlikely to benefit from additional related, identical, or similar services;

(k) For copying or preparing records or documents, except those Administrative Medical Reports requested by the branch offices or the Division for casework planning or eligibility determinations;

(L) Whose primary intent is to improve appearances, exceptions subject to the HERC coverage and guidelines;

(m) Similar or identical to services or items that shall achieve the same purpose at a lower cost and where it is anticipated that the outcome for the client shall be essentially the same;

(n) For the purpose of establishing or reestablishing fertility or pregnancy;

(o) Items or services that are for the convenience of the client and are not medically or dentally appropriate;

(p) The collection, processing, and storage of autologous blood or blood from selected donors unless a physician certifies that the use of autologous blood or blood from a selected donor is medically appropriate and surgery is scheduled;

(q) Educational or training classes that are not intended to improve a medical condition;

(r) Outpatient social services except maternity case management services and other social services described as covered in the individual provider rules;

(s) Post-mortem exams or burial costs;

(t) Radial keratotomies;

(u) Recreational therapy;

(v) Telephone calls except for:

(A) Tobacco cessation counseling as described in OAR 410-130-0190;

(B) Maternity case management as described in OAR 410-130-0595;

(D) Services specifically identified as allowable for telephonic delivery when appropriate in the mental health and substance use disorder procedure code and reimbursement rates published by the Addiction and Mental Health division.

(w) Services that have no standard code set as established according to 45 CFR 162.1000 to 162.1011, unless the Division has assigned a procedure code to a service authorized in rule;

(x) Whole blood (Whole blood is available at no cost from the Red Cross). The processing, storage, and costs of administering whole blood are covered;

(y) Services that are requested or ordered but not provided to the client, unless specified otherwise in individual program rules;

(z) Missed appointments, an appointment that the client fails to keep. Refer to OAR 410-120-1280;

(aa) Transportation to meet a client's personal choice of a provider;

(bb) Alcoholics Anonymous (AA) and other self-help programs;

(cc) Medicare Part D covered prescription drugs or classes of drugs and any cost sharing for those drugs for Medicare-Medicaid Fully Dual Eligible clients, even if the Fully Dual Eligible client is not enrolled in a Medicare Part D plan. See OAR 410-120-1210 for benefit package;

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065 & ORS 414.025
DMAP 115-2024, amend filed 07/31/2024, effective 08/01/2024
DMAP 97-2023, amend filed 12/27/2023, effective 01/01/2024
DMAP 84-2023, amend filed 11/30/2023, effective 12/01/2023
DMAP 82-2023, amend filed 10/18/2023, effective 10/18/2023
DMAP 20-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 86-2022, amend filed 11/30/2022, effective 12/01/2022
DMAP 2-2021, minor correction filed 01/15/2021, effective 01/15/2021
DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14
DMAP 71-2013, f. & cert. ef. 12-27-13
DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru 12-24-13
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 15-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 24-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 56-2003, f. 8-28-03, cert. ef. 9-1-03
OMAP 46-2003(Temp), f. & cert. ef. 7-1-03 thru 12-15-03
OMAP 17-2003(Temp), f. 3-13-03, cert. ef. 3-14-03 thru 8-15-03
OMAP 8-2003, f. 2-28-03, cert. ef. 3-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 42-2002, f. & cert. ef. 10-1-02
OMAP 22-2002, f. 6-14-02, cert. ef. 7-1-02
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 31-1999, f. & cert. ef. 10-1-99
OMAP 10-1999, f. & cert. ef. 4-1-99
OMAP 20-1998, f. & cert. ef. 7-1-98
OMAP 12-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98
HR 21-1997, f. & cert. ef. 10-1-97
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 6-1996, f. 5-31-96, cert. ef. 6-1-96
HR 40-1994, f. 12-30-94, cert. ef. 1-1-95
HR 31-1994, f. & cert. ef. 11-1-94
HR 2-1994, f. & cert. ef. 2-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0420, 410-120-0460 & 410-120-0480
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 41-1991, f. & cert. ef. 10-1-91
HR 27-1991 (Temp), f. & cert. ef. 7-1-91
HR 32-1990, f. 9-24-90, cert. ef. 10-1-90
HR 23-1990(Temp), f. & cert. ef. 7-20-90
HR 19-1990, f. & cert. ef. 7-9-90
HR 5-1990(Temp), f. 3-30-90, cert. ef. 4-1-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0055; 461-013-0103, 461-013-0109 & 461-013-0112
AFS 70-1988, f. & cert. ef. 12-7-88
AFS 58-1988(Temp), f. & cert. ef. 9-27-88
AFS 53-1988(Temp), f. 8-23-88, cert. ef. 9-1-88
AFS 51-1988(Temp), f. & cert. ef. 8-2-88
AFS 29-1987(Temp), f. 7-15-87, cert. ef. 7-17-87
AFS 54-1987, f. 10-29-87, ef. 11-1-87
AFS 10-1987, f. 2-27-87, cert. ef. 3-1-87
AFS 78-1986(Temp), f. 12-16-86, cert. ef. 1-1-87
AFS 57-1986, f. 7-25-86, cert. ef. 8-1-86
AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85
AFS 61-1983, f. 12-19-83, cert. ef. 1-1-84
AFS 43-1983, f. 9-2-83, cert. ef. 10-1-83
AFS 31-1983(Temp), f. 6-30-83, cert. ef. 7-1-83
AFS 15-1983(Temp), f. & cert. ef. 4-20-83
AFS 103-1982, f. & cert. ef. 11-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
PWC 812, f. & cert. ef. 10-1-76, Renumbered from 461-013-0030
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1210 Medical Assistance Benefit Packages and Delivery System

(1) The services clients are eligible to receive are based on their benefit package. Not all packages receive the same benefits.

(2) The Health Systems Division (Division), Medical Assistance Programs benefit package description, codes, eligibility criteria, coverage, limitations, and exclusions are identified in these rules.

(3) The limitations and exclusions listed here are in addition to those described in OAR 410-120-1200 and in any chapter 410 OARs.

(4) Benefit package descriptions:

(a) Oregon Health Plan (OHP) Plus:

(A) Benefit package identifier: BMH;

(B) Eligibility criteria: As defined in federal regulations and in the 1115 OHP waiver demonstration, a client is categorically eligible for medical assistance if they are eligible under a federally defined mandatory, selected, optional Medicaid program or the Children's Health Insurance Program (CHIP) and also meets Oregon Health Authority (Authority) adopted income and other eligibility criteria;

(i) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage for individuals under age 21 and individuals who qualify for the Young Adults with Special Health Care Needs (YSHCN) program, as detailed in Chapter 410 Division 151.

(ii)Services consistent with the Health Evidence Review Commission (HERC) Prioritized List of Health Services (Prioritized List), (OAR 410-141-3820 through 410-141-3830);

(iii) Ancillary services, (OAR 410-141-3820);

(iv) Substance use disorder treatment and recovery services provided through local substance use disorder treatment and recovery providers;

(v) Mental health services based on the Prioritized List to be provided by Board licensed, certified, or credentialed providers or through Community Mental Health Programs certified and credentialed providers;

(vi) Hospice;

(vii) Post-hospital extended care benefit up to a one hundred (100) day stay in a nursing facility for non-Medicare Division clients who meet Medicare criteria for a post-hospital skilled nursing placement. This benefit requires prior authorization by pre-admission screening (OAR 411-070-0043) or by the Coordinated Care Organization (CCO) for clients enrolled in a CCO; and

(viii) HRSN Services (OAR 410-120-2005).

(D) Limitations: Except for individuals who qualify for the Young Adults with Special Health Care Needs program (see OAR 410-200-0455), the following services have limited coverage for non-pregnant adults age 21 and older, who are outside of the protected postpartum eligibility period (see OAR 410-200-0135). (Refer to the cited OAR chapters and divisions for details):

(i) Selected dental (OAR chapter 410, division 123 and 200);

(ii) Vision services such as frames, lenses, contacts corrective devices and eye exams for the purpose of prescribing glasses or contacts (OAR chapter 410, division 140 and 200).

(b) OHP with Limited Drugs:

(A) Benefit package identifier: BMM, BMD;

(B) Eligibility criteria: Eligible clients are eligible for Medicare and Medicaid benefits;

(D) Limitations:

(i) The same as OHP Plus as described in this rule;

(ii) Drugs excluded from Medicare Part D coverage that are also covered under the medical assistance programs, subject to applicable limitations for covered prescription drugs (Refer to OAR chapter 410, division 121 for specific limitations). These drugs include but are not limited to:

(I) Over-the-counter (OTC) drugs;

(II) Barbiturates (except for dual eligible individuals when used in the treatment of epilepsy, cancer or a chronic mental health disorder as Part D shall cover those indications).

(E) Exclusions: Drugs or classes of drugs covered by Medicare Part D Prescription Drug;

(F) Payment for services is limited to the Medicaid-allowed payment less the Medicare payment up to the amount of co-insurance and deductible;

(G) Cost sharing related to Medicare Part D is not covered since drugs covered by Part D are excluded from the benefit package.

(A) Benefit Package identifier code MED;

(B) Eligibility criteria: Eligible clients are Medicare Part A and B beneficiaries who have limited income but do not meet the income standard for full medical assistance coverage;

(C) Coverage: Is limited to the co-insurance or deductible for the Medicare service. Payment is based on the Medicaid-allowed payment less the Medicare payment up to the amount of co-insurance and deductible but no more than the Medicare allowable;

(D) Providers may not bill QMB-only clients for the deductible and coinsurance amounts due for services that are covered by Medicare;

(E) Medicare is the source of benefit coverage for service; therefore, an OHP 3165 is not required for this eligibility group. A Medicare Advance Beneficiary Notice of Noncoverage (ABN) may be required by Medicare, refer to Medicare for ABN requirements.

(d) Citizenship Waived Medical (CWM) Benefit Package defined in OAR 410-120-0000. Refer to OARs 410-134-0005(2) and 410-134-0005(3) for coverage and billing guidance.

(e) Compact of Free Association (COFA) Dental Program:

(A) Benefit Package identifier code DEN;

(B) Eligibility criteria: Eligible clients are specified in OAR 410-200-0445;

(C) Coverage is state funded and includes the types and extent of Dental services that the Authority determines shall be provided to medical assistance recipients in accordance with OAR chapter 410 division 123.

(D) Coverage also includes pharmaceuticals prescribed by a dental health care provider as component of covered dental services.

(E) No copayments, deductibles or cost sharing shall be required for eligible clients.

(f) Veteran Dental Program:

(A) Benefit Package identifier code DEN and DNT;

(B) Eligibility criteria: Eligible clients are specified in OAR 410-200-0445;

(C) Coverage is state funded and includes the types and extent of dental services that the Authority determines shall be provided to medical assistance recipients in accordance with OAR chapter 410 division 123.

(D) Coverage also includes pharmaceuticals prescribed by a dental health care provider as component of covered dental services.

(E) No copayments, deductibles or cost sharing shall be required for eligible clients.

(g) Young Adults with Special Health Care Needs (YSHCN) Program:

(A) Benefit package identifier codes BMH, BMM, or BMD;

(B) Eligibility criteria: Eligible clients are specified in OAR 410-200-0455;

(i) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage as described in chapter 410 Division 151;

(ii) All dental and vision services available to EPSDT beneficiaries, as detailed in chapter 410 Division 123 and chapter 410 Division 140; and

(iii) Health-Related Social Needs or “HRSN” services (as defined in OAR 140-120-0000 and detailed in OAR 410-120-2000) are available to those receiving YSHCN as an “HRSN Covered Population”.

(D) Limitations: Individuals receiving OHP Plus benefits under the YSHCN program are not eligible for long-term care services and supports under Oregon’s 1915(c) waiver, and HRSN services must be annually reassessed for eligibility for HRSN services as set out in OAR 410-120-2015.

(5) Division clients are enrolled for covered health services and HRSN Services to be delivered through one of the following means:

(a) Coordinated Care Organization (CCO):

(A) These clients are enrolled in a CCO that provides integrated and coordinated health care;

(B) CCO services are obtained from the CCO or by referral from the CCO that is responsible for the provision and reimbursement for physical health, substance use disorder treatment and recovery, mental health services, dental care, or HRSN Services.

(b) Fee-for-service (FFS):

(A) These clients are not enrolled in a CCO;

(B) Subject to limitations and restrictions in the Division’s individual program rules, the client may receive health care from any Division-enrolled provider that accepts FFS clients. The provider shall bill the Division directly for any covered service and shall receive a fee for the service provided.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042, ORS 414.025, 414.065, 414.329, 414.706, 414.710, 414.432, 414.312, 414.430, 414.690, 414.572, 414.605, 414.665, 414.719 & SB 269-b (2025)
DMAP 86-2025, amend filed 12/05/2025, effective 01/01/2026
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 130-2024, amend filed 10/24/2024, effective 11/01/2024
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 5-2023, minor correction filed 02/17/2023, effective 02/17/2023
DMAP 90-2022, amend filed 12/19/2022, effective 01/01/2023
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 14-2022, temporary amend filed 02/16/2022, effective 02/16/2022 through 07/06/2022
DMAP 4-2022, temporary amend filed 01/11/2022, effective 01/11/2022 through 07/06/2022
DMAP 3-2022, temporary amend filed 01/07/2022, effective 01/08/2022 through 07/06/2022
DMAP 2-2022, temporary amend filed 01/07/2022, effective 01/07/2022 through 01/07/2022
DMAP 23-2021, amend filed 06/22/2021, effective 07/01/2021
DMAP 71-2018, minor correction filed 06/01/2018, effective 06/01/2018
DMAP 70-2018, amend filed 05/31/2018, effective 06/01/2018
DMAP 16-2018, temporary amend filed 03/15/2018, effective 03/15/2018 through 06/29/2018
DMAP 55-2017, temporary amend filed 12/26/2017, effective 01/01/2018 through 06/29/2018
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 71-2013, f. & cert. ef. 12-27-13
Reverted to DMAP 31-2013, f. & cert. ef. 6-27-13
DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru 12-24-13
DMAP 31-2013, f. & cert. ef. 6-27-13
DMAP 63-2012(Temp), f. 12-27-12, cert. ef. 1-1-13 thru 6-29-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04
OMAP 56-2003, f. 8-28-03, cert. ef. 9-1-03
OMAP 46-2003(Temp), f. & cert. ef. 7-1-03 thru 12-15-03

Or. Admin. R. 410-120-1215 Fee-for-Service Care Coordination: Administration

(1) The Authority or its designee shall provide Open Card Members with Care Coordination services. Care Coordination includes all physical, developmental, behavioral, oral health services accessed and as requested by the Open Card Member. Care Coordination also addresses Open Card Members’ Health-Related Social Needs (HRSN) in support of addressing barriers related to Social Determinants of Health and Equity (SDOH-E). Physical, developmental, behavioral, and oral health services together with services provided to address HRSN and SDOHE, are collectively called, “OHP Services.” The Authority’s desired goal for the sustained provision of Care Coordination over a substantial time-period is to:

(a) Improve Open Card Member health outcomes;

(b) Support and enable an Open Card Member’s ability to manage, maintain and improve any chronic conditions or disabilities;

(2) The Authority or its designee must provide Open Card Members with Care Coordination that:

(a) Identifies the Open Card Member’s need for OHP Services on an initial and ongoing basis, as described in OARs 410-120-1220 and 410-120-1225;

(b) Is provided or accessed promptly after enrollment in the fee-for-service (FFS) delivery system and on an ongoing basis while enrolled in the FFS delivery system.

(3) The Authority or its designee must provide Care Coordination to Open Card Members regardless of which Provider provides the OHP Services.

(4) When a Member transitions from one OHP delivery system to another (CCO or FFS), the predecessor entity shall ensure that all documentation in relation to the Member’s Care Coordination (Care Profile, Care Plan, HRA, etc.) is provided to the receiving entity in compliance with section (11) of this rule.

(5) The Authority or its designee may provide Care Coordination for the following services, upon request of the Open Card Member, if the Open Card Member also receives:

(a) Health care services covered by Medicare or Medicare Advantage Plans; or

(b) Services from state, local, community, or social support agencies or organizations, including but not limited to, Community Mental Health Programs (CMHP), Oregon Department of Human Services (ODHS), including Aging and People with Disabilities (APD), Child Welfare (CW), and Office of Developmental Disability Services (ODDS), Oregon Department of Education (ODE), Oregon Youth Authority (OYA), Coordinated Care Organizations (CCO), local public and mental health authorities, or any other institutional, community, and social support organizations serving the Open Card Member.

(6) If an Open Card Member receives all their OHP Services through the Authority’s FFS delivery system, the Authority or its designee must provide the Open Card Member with all Care Coordination services.

(a) The Authority or its designee is primarily responsible for the Care Coordination for Members who are enrolled in plan type CCOE, CCOF or CCOG;

(b) If an Member is enrolled in a CCO to receive some services (plan types CCOA or CCOB), the CCO is responsible for providing care coordination services except in certain circumstances when the Authority is responsible for paying for specific services, including but not limited to, Long-Term Services and Supports (LTSS), some Behavioral Health services, and other services carved-out in the CCO contract. In those circumstances the CCO shall:

(A) Proactively collaborate with the Authority or its designee regarding the CCO’s respective Care Coordination obligations for the services that are paid for by the Authority; and

(B) Provide the CCO Member’s care team with written notice that the Authority and other parties are involved in the CCO Member’s care, provide the care team with the contact information for all other involved parties and instruct the care team that they must communicate with all parties that make up the CCO Member’s care team regarding the CCO Member’s needs; and

(C) Communicate with the Authority and other care team members about the CCO Member’s Care Plan(s) and ensure that all OHP Services accessed by the CCO Member, whether covered and paid for by the CCO or the Authority, are coordinated in collaboration with the Authority.

(7) When Open Card Members are receiving OHP Services from multiple programs or delivery systems (e.g., Long Term Services and Supports, Intellectual and Developmental Disabilities, Child Welfare, Youth Wraparound, Intensive In-home Behavioral Health Treatment, etc.) and those programs also engage their own care teams or coordinators in providing their respective services, the Authority or its designee may collaborate with those additional programs that are coordinating the Open Card Member’s services in order to reduce duplication of services and identify and fill Care Coordination gaps. In those cases, the Authority or its designee must:

(a) Document both the other programs’ coordinating activities and identify any other Care Coordination needs the Open Card Member may have; and

(b) Provide Care Coordination to the Open Card Member for all needs identified that are not addressed or coordinated by another program.

(8) The Authority or its designee must document, track, and monitor Care Coordination services of Open Card Members for purposes of care planning, setting health goals and outcomes;

(a) Documentation must be stored and maintained in a single file for each Open Card Member that results in the creation of an Open Card Member Care Profile that complies with the requirements set out in OAR 410-120-1220;

(b) Monitoring must utilize baseline data relating to the Open Card Member’s health and then be compared to data that is subsequently collected and analyzed.

(9) Open Card Members are identified by the designated care coordinator as: no- or low-risk, moderate-risk, or high-risk.

(a) The designated care coordinator must determine the risk level using the Authority’s then-current risk stratification mechanisms and algorithms. The data sources used must include, without limitation:

(A) Claims and utilization data;

(B) Health Risk Assessments performed and utilized in accordance with OAR 410-120-1220;

(D) Referrals, event notifications, and other available resources that provide relevant information regarding the Open Card Member’s physical, developmental, behavioral, oral health care needs, the need for HRSN services, and the over-all impact SDOH-E in the Open Card Member’s health.

(b) Data sources are used to identify risks, risk level, and care gaps. Continuous and ongoing data mining and identification of additional care gaps shall inform updates to the Open Card Member’s risk level, Care Profile, Care Plan, OHP Service needs, and interventions needed;

(c) Risk scores are utilized, in conjunction with the application of appropriate clinical subjectivity by health care Providers to further interpret objective and subjective patient information to determine the Open Card Member’s risk level and inform the overall Care Coordination planning process.

(10) Open Card Members have the right to exercise their Grievance, complaint and Appeal rights under OARs 410-120-1860 and 410-120-1865 for Grievances and Appeals pertaining to Care Coordination.

(11) The Authority or its designee must provide Open Card Members requesting Care Coordination services with a designated care coordinator who has the training and experience necessary to meet OHA’s care coordinator qualifications (designated care coordinator).

(a) The Authority or its designee may provide Open Card Members (or their authorized Representative) with:

(A) The contact information for their designated care coordinator and for an alternate care coordinator when the designated care coordinator is unavailable;

(B) Prompt access to their complete Care Profile, in accordance with 45 CFR §164.524, and all other records pertaining to provided services, up-to-date and complete per OAR 410-120-1360 (Requirements for Financial, Clinical and Oher Records);

(b) At the Open Card Member’s request, the Authority or its designee may provide the Care Profile to a third-party the Open Card Member has identified.

(c) Exclusions and limitations to Open Card Member Care Coordination information sharing are included in OAR 410-120-1225.

(12) The Authority or its designee must develop, maintain, disclose, or otherwise share all information and documentation regarding an Open Card Member’s Care Coordination services and all other information related to the provision and administration of the Open Card Member’s OHP Services in accordance with, as applicable, 45 CFR Parts 160 and 164 (HIPAA), 42 CFR Part 2, 42 CFR §431.300, as well as all applicable state privacy and information security laws, including without limitation ORS 192.553 through 192.581 and OAR Chapter 943, Division 014.

History

Statutory/Other Authority: ORS 413.042, 414.065 & ORS 414.033
Statutes/Other Implemented: ORS 414.033
DMAP 25-2026, adopt filed 06/26/2026, effective 07/01/2026

Or. Admin. R. 410-120-1221 Fee-for-Service Care Coordination: Identification of Open Card Member Needs

(1) The Authority or its designee must provide Open Card Members with Care Coordination services based on their level of need. To determine an Open Card Member’s level of need, a Health Risk Assessment (HRA) must be conducted, and a Care Profile must be created as described in this rule;

(a) Based on the results of the HRA and other information that is collected and analyzed for the purpose of developing a Care Profile of an Open Card Member, the Member may, as described in this rule, have a Care Plan developed that will guide the Care Coordination services provided by the Authority or its designee. If the Open Card Member’s Care Profile does not require, as set out in this rule, a Care Plan, the Member may request that a Care Plan be developed and utilized by the Authority or its designee in providing Care Coordination services;

(b) The Authority or its designee must provide Care Coordination services, as described in OAR 410-120-1225, to Open Card Members regardless of a Care Plan being developed.

(2) The Authority or its designee must provide an initial HRA, within 90 days of enrollment, or sooner if the Open Card Member’s health status requires. The results of an HRA are utilized to determine, along with other relevant information, an Open Card Member’s health care needs and Health-Related Social Needs. That information is then used to create a Care Plan that identifies the appropriate OHP Services and the scope of the Care Coordination services an Open Card Member will be provided to support access to the identified OHP Service needs. Refusal or failure to complete an HRA by an Open Card Member shall not limit the Open Card Member’s access to other Care Coordination services and supports.

(3) The HRA must be provided by the Open Card Member’s designated care coordinator using a standardized tool provided by or approved by the Authority and in the Member’s preferred method of communication and language. The designated care coordinator must:

(a) Contact the Open Card Member to complete the HRA using the Member’s identified preferred method of contact and language in accordance with Section 1557 of the Affordable Care Act (ACA);

(A) If the Open Card Member cannot be contacted on the first attempt, the care coordinator must make at least two (2) other attempts to provide additional information or support to the Member to complete the HRA. This must include attempts to reach the Member utilizing two (2) mixed modalities (e.g., paper, telephone, text (SMS), email or other methods that consider known or previously requested language access aids such as large print, video, braille), on different days and at different times;

(B) The Open Card Member has the right to decline to participate in the HRA;

(b) Make the results of the HRA available to the Open Card Member, their Representative or guardian in their preferred language and preferred method of communication whether orally or in writing, and either on paper or electronically or other methods in accordance with Section 1557 of the Affordable Care Act as large print, video, braille;

(c) Review and document an Open Card Member’s HRA in their Care Profile in accordance with OAR 410-120-1215(7) or the Member’s general health care record;

(d) Share the results of the HRA with other entities and Providers serving the Open Card Member for the purpose of reducing duplication of those activities; and

(e) When the Open Card Member, their Representative or guardian has not returned or responded to the HRA:

(A) Use other available data sources, including but not limited to those identified in OAR 410-120-1215(3) and section (3) of this rule, to identify sufficient information to assign a risk level to the Open Card Member; and

(B) Ensure services are coordinated for Open Card Members regardless of their participation in, or completion of the HRA.

(4) Each Open Card Member has the right to have a Care Profile developed, updated, and maintained by the Authority or the Authority’s designee. Each care profile may include, without limitation, the following information:

(a) Personal information, including but not limited to:

(A) Demographic information;

(B) Communication preferences and needs (e.g. preferred language, method of contact (telephone, SMS, email), alternate formats, auxiliary aids and services);

(D) Name and contact information for any authorized Representative;

(E) Name and contact information for any legal guardian or authorized Representative, including parents;

(b) Completed assessments, including the Health Risk Assessment developed in accordance with this rule;

(d) The names of the Open Card Members’ care team, including but not limited to:

(A) Designated care coordinator;

(B) Health care Providers (e.g. primary care provider, behavioral health provider, specialists, etc.);

(D) Assigned care coordination responsibilities;

(E) Provider entities such as those identified in 410-120-1215, with specific individuals named as the point of contact;

(e) The Open Card Member’s identified needs;

(f) An overview of the supports, services, activities and resources that have been or will be deployed to meet the Open Card Member’s needs;

(g) The Open Card Member’s desire to participate in Care Coordination and assessments, care planning, etc.;

(h) Current and any previously documented health-related circumstances;

(i) Current Care Plan and any other open or closed Care Plan(s);

(j) Communications to or from identified care team providers;

(k) Communications with the Open Card Member; and

(l) Other similar information.

(5) The Authority or its designee must develop a Care Plan for Open Card Members who have been identified has having specific health-risk scores in accordance with OAR 410-120-1215;

(a) The Authority or its designee must develop a care plan for Open Card Members in the moderate-risk and high-risk levels, or who require Long Term Service and Supports (LTSS);

(b) The Authority or its designee must develop a care plan for Open Card Members in the no- or low-risk levels when the Member’s needs change resulting in a higher risk level or when the Member or their authorized representative or guardian requests it;

(c) Development of a Care Plan is one part of the Care Coordination process and service. The Authority may provide Open Card Members, or their authorized Representatives or guardians (or all of them), with the opportunity to participate in the development of the Member’s Care Plan;

(A) Care Plans developed with the participation of the Open Card Member, must be developed in keeping with the process identified in OAR 410-120-1225; and

(B) Open Card Members identified as moderate or high-risk who decline participation in Care Plan development, may still have Care Plans developed for them by the designated care coordinator. Care Plans developed by the designated care coordinator must be documented, made part of the Open Card Member’s Care Profile, and utilize the relevant information and sources identified in OAR 410-120-1215(4). At a minimum, the designated care coordinator must include the following information:

(i) The Open Card Member’s physical, developmental, behavioral, oral, and social needs (including Health Related Social Needs and Social Determinants of Health and Equity), when available; and

(ii) Services and activities the designated care coordinator has or plans to deploy to focus on mitigation of the Open Card Member’s identified risks and level; and

(iii) Outreach attempts and opportunities for engagement the designated care coordinator continues to provide to the Open Card Member; and

(iv) The reason the Open Card Member (or their legal guardian or their authorized Representative) has declined or is otherwise unable to participate in the development of their Care Plan;

(C) For Open Card Members receiving LTSS, the designated care coordinator must be provided with access to or integrate any service or Care Plans developed by entities listed in OAR 410-120-1215(4) into the Member’s Care Profile or Care Plan, or both;

(d) The Authority or its designee may utilize the Care Plan to ensure continuity of an Open Card Member’s care according to their needs;

(e) The Authority or its designee may utilize the Care Plan to determine the scope of Care Coordination services provided to the Open Card Member as described in OAR 410-120-1225.

(6) The Authority or its designee must assess Open Card Members for the need for LTSS and Special Health Care Needs (SHCNs) as those terms are defined in OAR 410-120-0000;

(a) The results of the Open Card Member’s HRA and other relevant assessments or documentation are used to identify the risk level and need for LTSS and SHCNs;

(b) If at any time, an Open Card Member is identified as potentially eligible for, or requiring LTSS, or services necessary to address their SHCNs, the Authority or its designee shall promptly refer to the Oregon Department of Human Services (ODHS), including Aging and People with Disability (APD) programs, the Office of Developmental Disabilities Services (ODDS), local mental health authorities (LMHA) or other service programs where appropriate for completion of a comprehensive assessment and potential service planning. That assessment must occur as soon as the health condition arises, to determine whether the Open Card Member requires either a course of treatment or regular care monitoring to address those conditions.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 25-2026, adopt filed 06/26/2026, effective 07/01/2026

Or. Admin. R. 410-120-1225 Fee-for Service Care Coordination: Service Coordination

(1) The Authority’s designee must provide Open Card Members Care Coordination services as described in this rule and in OARs 410-120-1215 and 410-120-1221.

(2) Upon enrollment, the Authority’s designee must provide Open Card Members with prompt Care Coordination services that facilitate access to any Urgent Care Services or Emergency Services (as defined in OAR 410-120-0000) the Member may need, even if the Member has not yet selected a Primary Care Provider (PCP) or completed the Health Risk Assessment (HRA).

(3) The Authority’s designee must provide Open Card Members Care Coordination services regardless of the location of eligible Provider(s).

(a) If an Open Card Member experiences a care setting transition, the designated care coordinator must:

(A) Transition the Open Card Member into the most appropriate independent and integrated community settings and provide follow-up services as Medically Necessary and Appropriate prior to discharge to facilitate successful handoff to community providers;

(B) Provide Care Coordination and discharge planning in accordance with the discharge plan;

(i) Is discharged for temporary placement in a residential facility (behavioral or physical health) outside the Open Card Member’s home or community; or

(ii) Was enrolled in OHP upon entering the Oregon State Hospital and will return to their home or community upon discharge;

(b) The designated care coordinator may coordinate and authorize care when it has been deemed Medically Necessary and Appropriate to receive services outside of the Open Card Member’s community due to the unavailability of the Medically Necessary services;

(c) The designated care coordinator must coordinate the Open Card Member’s care when the Member is temporarily outside their community;

(d) The Authority or its designee shall provide the Post-Hospital Extended Care (PHEC) benefit according to the criteria established by Medicare, as cited in the Medicare Coverage of Skilled Nursing Facility Care.

(4) When an Open Card Member’s Care Profile identifies the Member as having moderate to high-risk health needs, the Authority’s designee must provide Care Coordination for OHP Services without request;

(a) For Open Card Members who have low health-risk needs, the Authority’s designee may provide Care Coordination services when requested by the Open Card Member, the Member’s Representative or guardian, or by a Provider or entity involved in the Member’s care;

(b) Open Card Members have the right to decline the provision of Care Coordination services at any time.

(5) To provide Care Coordination services, a Care Plan may be developed and implemented by the designated care coordinator to address the needs, goals, preferences, and circumstances of the Open Card Member as described in OARs 410-120-1215 and 410-120-1221.

(a) The Authority’s designee must review, update, or revise any applicable Care Plan(s) annually and as follows:

(A) When requested by the Open Card Member, the Member’s Representative or guardian, or any Provider involved in or providing care to the Open Card Member; or

(B) Upon a change in health-related circumstances as described in OAR 410-120-1221;

(b) For Open Card Members who decline to participate in the development of their Care Plan, the Authority’s designee shall develop Care Plans in keeping with, at minimum, the requirements set forth in OAR 410-120-1221, and to the extent possible given due to the Open Card Members’ lack of participation, in keeping with the requirements set forth in subsection (5)(c) below of this rule;

(c) For Open Card Members who participate in the development of their Care Plan, the Authority’s designee must develop and revise the Care Plan in alignment with all the following:

(A) The Open Card Member’s identified needs and risk level; and

(B) The Open Card Member’s identified goals and preferences, when available, to the extent the Member desires or can participate; and

(C) By incorporating information from any relevant assessments, treatment and service plans from Providers or community partners involved in the Open Card Member’s care, to the maximum extent feasible; and

(D) In consultation with any other Provider, case manager, or entity providing services to, or coordinating care for, the Open Card Member; and

(E) In consultation with a clinician that has the appropriate clinical qualifications and expertise to review and revise the Care Plan considering the Open Card Member’s complex physical, developmental, behavioral or oral health care needs including clinical subjectivity; and

(F) In accordance with an Open Card Member’s updated risk level as described in paragraph (5)(a)(B) of this rule; and

(G) In accordance with state quality assurance and utilization review standards, as applicable; and

(H) With the Open Card Member, their Representative or guardian’s participation (or all of them) to the extent they desire or can participate;

(i) The Care Plan must be agreed to and approved by the Open Card Member, their Representative or guardian;

(ii) The Open Card Member, their Representative or guardian, must understand the Care Plan, including the components that identify any roles and responsibilities the Member will perform themselves;

(d) If the designated care coordinator determines that the participation of the Open Card Member, the Member’s authorized Representative, or family in the creation of their Care Plan may be detrimental to the Open Card Member’s care or health, those individuals may be excluded from the development of the Member’s Care Plan. In these situations:

(A) The reasons for the exclusion must be documented in the Care Plan and include a specific description of the risk or potential harm that the Open Card Member would experience or would be at risk of experiencing if the Member, their authorized Representative, or family, were included in the development of the Care Plan. The documentation of the decision must also include a description of the attempts made to address the concern(s) without having to exclude the individuals from the process; and

(B) The decision regarding exclusion from participation must be reviewed, reconsidered, and redetermined prior to each update of a Care Plan. If it is determined the exclusion is still required, that decision must be documented in the Open Card Member’s care plan in accordance with paragraph (5)(d)(A) above;

(e) Except as permitted under paragraph (5)(e)(C) of this rule, the Authority or its designee must provide the Open Card Member, and if applicable, their authorized Representative or guardian, a copy of the Member’s Care Plan promptly after it has been completed. The designated care coordinator must also promptly provide the completed Care Plan to all Providers who will be rendering services to the Open Card Member in keeping with the Care Plan;

(A) If the Care Plan is required to be approved, then approval must be made in a timely manner. Timeliness is determined by the Open Card Member’s health needs;

(B) Once the Care Plan is completed, and if applicable, approved, the Authority or its designee must provide the Open Card Member, their Representative or guardian prompt electronic access to the Care Plan;

(i) If the Open Card Member prefers a different method of communication, the Member may promptly receive a paper copy of their Care Plan;

(ii) The Authority or its designee shall provide the Open Card Member’s Care Plan in the Member’s preferred language;

(iii) In accordance with Section 1557 of the Affordable Care Act and OAR 410-120-1215, the Open Card Member has a right to receive or otherwise access their Care Plan through the use of auxiliary aids and services, in alternate formats, or other means, promptly upon request. For purposes of this subparagraph, “promptly” means within five (5) business days after the date of the Open Card Member’s request;

(C) If it is determined by the Open Card Member’s care team that providing the Member with full or partial access to the Care Plan could be significantly detrimental to the Member’s care or health, the designated care coordinator may withhold from the Member only those parts of the Care Plan that have been determined to be detrimental. When a designated care coordinator withholds all or part of an Open Card Member’s Care Plan, the designate care coordinator must:

(i) Document in the Open Card Member’s Care Plan the reasons for withholding the full or partial Care Plan, including a specific description of the risk or potential harm that was the basis for the determination. The documentation must also describe what attempts were made to address the concern(s) prior to determining that the Care Plan should be fully or partially withheld; and

(ii) Review the decision to withhold the full or partial Care Plan prior to each Care Plan update and reevaluate the decision to withhold the Care Plan upon completion of the updated Care Plan prior to making any decision to continue fully or partially withholding the updated Care Plan. If, upon reevaluation, the decision is to continue to withhold all or part of the Care Plan, that decision must be documented in the Open Card Member’s Care Plan keeping with subparagraph (5)(e)(C)(i) of this rule;

(f) An Open Card Member’s care plan must be closed when:

(A) It is no longer warranted by the Member’s risk level or circumstances; or

(B) Requested by the Member, their Representative or guardian;

(g) An Open Card Member’s Care Plan may, but is not required to, be closed when the designated care coordinator has not been able to make contact with the Open Card Member, their Representative or guardian, after a minimum of three (3) attempts of outreach utilizing the Member’s preferred method of communication and language and using at least two (2) mixed modalities (e.g., paper, email, telephone, or text (SMS) ), over a 60 day period and with consultation and agreement of available care team members;

(h) If an Open Card Member no longer wishes to participate in their Care Plan, and the Member continues to be identified as medium – or high-risk, or continues to receive LTSS, the designated care coordinator must transition the Open Card Member to a directed Care Plan as outlined in OAR 410-120-1221(4)(c)-(e);

(i) The Authority or its designee shall keep an Open Card Member’s Care Profile up-to-date even if the Member declined to participate in the Care Plan or the Care Plan has been closed, regardless of the reason for the closure.

(6) The Authority or its designee may provide Open Card Members with opportunities to meet with an interdisciplinary team:

(a) The Authority or its designee must provide opportunities to meet with an interdisciplinary team to Open Card Members who receive LTSS or have been identified as having Special Health Care Needs, as defined in OAR 410-120-0000, and who have been assessed in accordance with OAR 410-120-1221(4) and require:

(A) A course of treatment; or

(B) Regular care monitoring; or

(b) Interdisciplinary team meetings must occur within 14 days of the Open Card Member’s transition between levels of care, settings of care, or episodes of care or as otherwise required by the Member’s Care Plan.

(A) The Open Card Member and their authorized Representative or guardian, unless the Member declines or the Member’s participation, or their authorized representative or guardian’s participation, is determined to be significantly detrimental to the Member’s health, in accordance with (5)(b)(G) of this rule;

(B) All of the available Open Card Member’s Providers; and

(C) Other available organizations or entities that provide OHP and other services to the Open Card Member, including without limitation, those listed in OAR 410-120-1215(4).

(D) In the event some of the above Providers, entities, or organizations are unable to attend the interdisciplinary meeting, the Authority or designated care coordinator will be responsible for obtaining the information and documentation from those Providers, entities, and organizations that is necessary to fulfill the purpose of the interdisciplinary team meeting as described in subsection (6)(d) of this rule;

(d) Interdisciplinary team meetings are held for the purpose of providing an opportunity for:

(A) The Open Card Member to provide an update and feedback on the care they have received, including the progress they have made toward their care plan goals, their strengths and challenges, and any change in those strengths and challenges since the last interdisciplinary team meeting was held;

(B) Other attendees to describe the clinical interventions, services, and treatment provided to the Open Card Member and the progress made in treating or otherwise addressing the Member’s health condition;

(C) All attendees to identify gaps in care and Care Coordination and strategies for filling or otherwise closing those gaps;

(D) Developing strategies for identifying, addressing, monitoring, and following up on the needs of the Open Card Member identified during the interdisciplinary meeting, including, without limitation, referrals for specialty care, routine health care services (including medication monitoring), other community program resources or social services that can meet the needs of the Member;

(E) Updating the Open Card Member’s Care Plan in keeping with the decisions made, information shared, and the Member’s needs identified during the interdisciplinary meeting; and

(F) Identifying, prior to ending the interdisciplinary meeting, the subsequent dates or frequency the interdisciplinary team will meet to address the Open Card Member’s Care Plan needs;

(e) The Care Plan, as updated during an interdisciplinary meeting, must be shared in accordance with subsections (4)(e)-(f) of this rule;

(f) If required by the Open Card Member’s health condition and identified needs, as identified as in the updated Care Plan, the Member must be provided with direct access to specialists, which may include a standing referral or an approved number of visits.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
DMAP 25-2026, adopt filed 06/26/2026, effective 07/01/2026

Or. Admin. R. 410-120-1260 Provider Enrollment

(1) This rule applies to providers requesting enrollment, currently enrolled, and previously enrolled with the Oregon Health Authority (Authority), Health Systems Division (Division).

(2) Providers signing the Provider Enrollment Agreement constitute agreement to comply with all applicable Authority provider rules, Oregon Department of Human Services (ODHS) provider rules, and federal and state laws and regulations applicable to Medicaid payments.

(3) Authority review of a provider application for enrollment, material change in a provider’s enrollment information, and any documentation received in response to an Authority re-validation request is based on a categorical risk level of limited, moderate, or high. If a provider falls within more than one risk level described in 42 CFR 455.450, the highest level of review is conducted by Authority. Authority will assign a risk level which meets or exceeds federal requirement and reserves the right to adjust provider risk level at any time when:

(a) Authority imposes a payment suspension, in accordance with OAR 410-120-1400, on a provider based on credible allegation of fraud, waste or abuse;

(b) The provider has an existing Medicaid overpayment which, including all outstanding depts and interest, is $1,500 or greater and all of the following:

(A) Is more than 30 calendar days old;

(B) Has not been repaid at the time the application for enrollment is filed;

(D) Is not part of an Authority approved extended repayment schedule for the entire outstanding overpayment.

(c) The provider has been excluded by the Office of Inspector General (OIG) or another state's Medicaid program within the previous 10 years; or

(d) Authority or CMS in the previous six (6) months lifted a temporary moratorium for the particular provider type, in compliance with 42 CFR 455.470 and 42 CFR 424.570, and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider at any time within six (6) months from the date the moratorium was lifted.

(4) Authority, CMS, its agents, or its designated contractors may, in accordance with 42 CFR 455.432, conduct pre- and post-enrollment on-site visits and unannounced inspections of any and all provider locations at any time, for all provider types.

(5) Providers enrolled by the Authority include:

(a) A non-billing provider, meaning a provider who is issued a provider number for purposes of screening, data collection or non-claims-use such as, but not limited to:

(A) Ordering or referring providers, required by 42 CFR 455.410, whose only relationship with the Authority is to order, refer, or prescribe services for Authority members;

(B) A billing agent or billing service submitting claims or providing other business services on behalf of a provider but not receiving payment in the name of or on behalf of the provider;

(b) A payable provider, meaning a provider who is issued a provider number for submitting health care claims for reimbursement from the Authority. A payable provider may be:

(A) The rendering provider;

(B) An individual, agent, business, corporation, clinic, group, institution, or other entity that in connection with the submission of claims or encounters receives or directs the payment on behalf of a rendering provider.

(6) When a payable provider is receiving or directing payment on behalf of the rendering provider, the payable provider must:

(a) Meet one of the following standards:

(A) Have a relationship with the rendering provider described in 42 CFR 447.10(g) and have the authority to submit the rendering provider enrollment application and supporting documentation on behalf of the rendering provider; and

(B) Is a contracted billing agent or billing service enrolled with the Oregon Health Authority to provide services with the submission of claims and to receive or direct payment in the name of the rendering provider pursuant to 42 CFR 447.10(f).

(b) Maintain and provide to the Authority upon request records indicating the billing provider's relationship with the rendering provider. This includes:

(A) Identifying all rendering providers for whom they bill or receive or direct payments at the time of enrollment;

(B) Notifying the Authority within 30 days using Authority forms of a change to the rendering provider’s enrollment record such as name, date of birth, address, Authority assigned provider numbers, National Provider Identification Numbers (NPI), Social Security Number (SSN), or the Employer Identification Number (EIN); and

(c) Prior to submission of any claims or receipt or direction of any payment from the Authority , obtain signed confirmation from the rendering provider that the billing entity or provider is authorized by the rendering provider to submit claims or receive or direct payment on behalf of the rendering provider. This authorization, and any limitations or termination of such authorization, must be signed by the rendering provider and maintained in the provider's files for at least seven (7) years following the submission of claims or receipt or direction of funds from the Authority.

(7) To facilitate timely claims and encounter processing and payment consistent with applicable privacy and security requirements for providers:

(a) The Authority requires all non-billing and payable providers to be enrolled consistent with the provider enrollment process described in this rule;

(b) If the provider uses electronic media to conduct transactions with the Authority or authorizes a non-billing provider, e.g. billing service or billing agent, to conduct such electronic transactions, the rendering provider must comply with the Authority Electronic Data Interchange (EDI) rules, OAR 943-120-0100 through 943-120-0200. Enrollment as a payable or non-billing provider is a necessary requirement for submitting electronic claims, but the provider must also register as an EDI trading partner and identify the EDI submitter in order to submit electronic claims; and

(c) The claims and encounters submitted to the Authority must include an NPI for each provider subject to the NPI requirements in 45 CFR Part 162 Subpart D. Rendering and referring providers may not have the same NPI listed on the claim or encounter. Billing and rendering providers may not have the same NPI listed on the claim or encounter.

(8) To be enrolled and able to bill and receive payment as a provider, an individual or organization must:

(a) Meet applicable licensing and regulatory requirements set forth by federal and state statutes, regulations, and rules. The provider’s license must be active. Authority may deny enrollment, re-enrollment or revalidation when a provider’s licensing body has placed limitations on the provider’s license or an action that created a limitation on the provider’s license impacts the quality or safety of services provided to OHP members. The Authority may request additional documentation from the provider or the licensing body or require additional screening.

(b) Comply with all Oregon statutes and regulations for provision of Medicaid and CHIP services. This includes meeting all applicable national and state licensure and certification requirements for all employees, subcontractors, vendors or other third parties providing services to Medicaid members for which the enrolled provider is receiving reimbursement from Authority;

(c) If providing services within Oregon, have a valid Oregon business license if such a license is a requirement of the state, federal, county, or city government to operate a business or to provide services; and

(d) Comply with all requests from Oregon Department of Justice (DOJ) Medicaid Fraud Control Unit (MFCU) for records and information when MFCU determines it is necessary to carry out its responsibilities. The records and information must be provided without charge and in the form requested by MFCU. A provider must comply with a request from MFCU for access to any records and information kept by providers to which OHA, ODHS, MCEs and MFCUs are authorized access by 42 CFR s431.107, including, but not limited to, any records necessary to disclose the extent of services provided to beneficiaries and any information regarding payments claimed by the provider for furnishing said services. The records and information must be provided without charge and in the form requested by MFCU. When a MFCU request for access is made in person such access must be granted immediately. A provider must make available to MFCU, copies of all procedural and policy statements, directives, and proposed or adopted regulations concerning the Medicaid program, and any other information relevant to the work of MFCU. Providers shall disclose protected health care information to the MFCU for oversight activities as authorized by 45 CFR s164.512(d).

(9) An Indian Health Service facility meeting enrollment requirements shall be enrolled on the same basis as any other qualified provider. However, when state licensure is normally required, the facility need not obtain a license but must meet all applicable standards for licensure.

(10) A provider that is currently subject to sanction by the Authority or the provider, a person with ownership or control of the provider, or a provider’s managing employee is excluded, sanctioned or suspended by the federal government or another state from Medicare or Medicaid participation the provider is not eligible for enrollment, consistent with OAR 410-120-1400, except when the Agency determines good cause exists, in accordance with 42 CFR 455.23;

(11) All providers listed in section (5) of this rule must provide the following information before the Authority may enroll and issue or revalidate an Authority assigned provider number. Information disclosed by the provider is subject to verification by Authority and all providers must provide documentation at any time upon written request by the Authority:

(a) The provider must disclose to the Authority the name, federal Tax Identification Number (TIN), date of birth, primary business address, every business location and P.O Box address of the provider and, as applicable, for the following:

(A) Each person who has a direct or indirect ownership or control interest in the provider, is an agent or is a managing employee of the provider, regardless of whether that person is an individual or corporate entity;

(B) Each person who has a direct or indirect ownership or control interest in the provider, is an agent or is a managing employee of the provider who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or the CHIP program in the last ten years;

(D) For the purpose of this rule, a person with direct or indirect ownership or control interest is defined in 42 CFR 455.101 and Authority calculates ownership and control percentage as required by 42 CFR 455.102.

(E) When disclosing tax identification numbers:

(i) For corporations, use the federal TIN;

(ii) For individuals use the Social Security Number (SSN);

(iii) All other providers use the EIN;

(iv) The SSN or EIN of the rendering provider may not be the same as the Tax Identification Number of the billing provider;

(v) Pursuant to 42 CFR 433.37, including federal tax laws at 26 USC 6041, SSN and EIN provided are used for the administration of federal, state, and local tax laws and the administration of this program for internal verification and administrative purposes including but not limited to identifying the provider for payment and collection activities.

(F) Whether any of the persons so named with an ownership or control interest in the provider requesting enrollment:

(i) Is related to another person with ownership or controlling interest in the provider requesting enrollment as a spouse, parent, child, sibling, or other family members by marriage or otherwise; and

(ii) The name of any other current or former Medicaid providers in which an owner of the provider requesting enrollment has an ownership or control interest.

(G) A provider shall submit, within 35 calendar days of the date of a request by the Authority full and complete information about:

(i) the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and

(ii) any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the five-year period ending on the date of the request.

(H) Failure to disclose or submit required information: Authority may not reimburse a provider for services furnished in the period beginning the day following the date the information was due to the Authority and ending on the day before the date on which the information was supplied. Authority will suspend or terminate the provider’s enrollment and Authority assigned provider number, in accordance with 42 CFR 455.104.

(b) The provider must submit required information to the Authority:

(A) Provider enrollment application based on the type of provider, Provider Enrollment Agreement, Provider Disclosure Statement, and all Attachments. Authority only accepts current versions of enrollment forms. All required forms are available at all times on OHA’s Provider Enrollment website;

(B) Application fee if required under 42 CFR 455.460;

(C) Consent to criminal background check to complete Authority established screening process and comply with 42 CFR § 455.410 and § 455.450 requirements for provider categories which pose increased financial risk of fraud, waste or abuse to the Medicaid program, 42 CFR § 455.434 when required;

(D) The Authority may use Medicare provider enrollment data to satisfy the requirement of (11)(b)(C), in this rule; and

(E) Copy of provider’s license, certification, or both.

(12) Authority may screen providers and validate information disclosed by providers as required under 42 CFR 455.436. Authority reserves the right to conduct and review providers requesting enrollment or revalidation in a more stringent manner than Medicare or other state Medicaid programs, conduct additional screening, or impose additional requirements on providers, or all three, for a provider or a group of providers identified by the Authority as at increased risk for fraud, waste or abuse.

(13) Authority may at its sole discretion require providers to enroll as a Medicare provider prior to enrolling in Oregon’s Medicaid program.

(14) Authority may implement 180-day moratoriums on the enrollment of providers in a specific service category, on a statewide basis, or within a specific Oregon geographic area, when the Authority determines the action is necessary to safeguard public funds or to maintain the fiscal integrity of the Oregon Medicaid program.

(15) Provider enrollment and the signed Provider Enrollment Agreement expires five (5) years from the date of enrollment. Authority will revalidate all enrolled providers at least every five (5) years, compliant with 42 CFR §455.414. Authority reserves the right to revalidate more frequently, at its discretion. Failure of a provider to respond to Authority notice or failure to return requested information for revalidation will result in termination of the provider enrollment agreement and Authority assigned provider number.

(16) Enrolled providers shall notify the Authority in writing using Authority forms within 35 calendar days of a material change in any status or condition that relates to their qualifications or eligibility to provide medical assistance services including, but not limited to, those listed in this subsection:

(a) Changes in federal TIN, SSN or EIN. Failure to notify the Authority of a change of Federal TIN for entities or a SSN, or EIN for individual providers may result in the imposition of a $50 fine per incident:

(b) Changes in business service location, affiliation, ownership, NPI, ownership and control information, or criminal convictions. The provider must notify the Authority using Agency provided forms;

(c) Providers who have more than one (1) NPI or receive a new NPI after enrolling with the Authority must complete a separate enrollment with the Authority for each NPI prior rendering services or listing the NPI on claims or encounters submitted to Authority.

(d) Bankruptcy proceedings, the provider shall immediately notify the Authority Provider Enrollment Unit in writing;

(e) Claims submitted by or payments made to providers who have not furnished the notification required by this rule or to a provider that fails to submit a new application as required by the Division under this rule may be denied or recovered.

(17) If Authority notifies the provider of an error in the federal TIN, the provider must supply the appropriate valid federal TIN within 35 calendar days of the date of Authority’s notice. Failure to comply with this requirement may result in Authority imposing a fine of $50 for each such notice. Federal TIN requirements described in this rule refer to any such requirements established by the Internal Revenue Service.

(18) Providers upon request may be enrolled by Authority up to 12 months prior to the date application for enrollment is received by the Authority only if:

(a) The provider is appropriately licensed, certified, and otherwise meets all federal and Authority requirements for providers at the time services are provided;

(b) The MCE submits to the Authority all required documentation to enroll the provider as an encounter only provider and that provider has an executed contract with and has successfully completed a credentialing process with the MCE;

(c) Upon request, the provider or MCE must submit to Authority a clear written statement as to why retro-enrollment is necessary to increase access to care and advance the triple aim.

(19) The Authority requires two types of provider numbers:

(a) The Authority issued Oregon Medicaid provider number which establishes an individual or organization’s enrollment as an Oregon Medicaid provider:

(A) The Provider Enrollment Agreement and the provider’s enrollment as an Oregon Medicaid provider is specific to the provider type and specialty type listed on the application for enrollment and constitutes a contractual relationship with the Authority. This Authority assigned number designates the specific categories of services covered by the Authority Provider Enrollment Agreement. For example, a pharmacy provider number applies to pharmacy services and cannot be used by the provider provide or bill for durable medical equipment.

(B) A provider seeking to render services or bill as more than one provider type shall complete a separate provider application and establish a separate Oregon Medicaid provider number;

(C) For providers not subject to NPI requirements, this Authority issued number is the provider identifier for billing the Authority.

(b) The Authority requires a National Provider Identification (NPI) in compliance with 45 CFR Part 162 Subpart D, for providers subject to NPI and Taxonomy requirements, as enumerated by the National Plan and Provider Enumeration System (NPPES). A provider must obtain an NPI and Taxonomy code prior to requesting enrollment and include these numbers in the application to request enrollment. The NPPES NPI information and provider applications are available at all times online: https://nppes.cms.hhs.gov/#/. For providers subject to NPI requirements:

(A) The NPI is the provider identifier for billing the Authority. The Provider Enrollment Agreement and the provider’s enrollment as an Oregon Medicaid provider is specific to the NPI listed on the application for enrollment and constitutes a contractual relationship with the Authority;

(B) Providers currently enrolled that obtain a new or additional NPI shall complete a new application for provider enrollment with the Division's Provider Enrollment Unit and the application must be approved by the Authority prior to the provider rendering or billing for services associated with that NPI;

(20) Enrolled providers are required to check the Prescription Drug Monitoring Program (PDMP) as defined in ORS 431A,655 before prescribing a schedule II-controlled substance pursuant to 42 U.S.C 1396w-3a.

(a) The PDMP check does not apply to clients in exempt populations:

(A) Individuals receiving hospice;

(B) Individuals receiving palliative care;

(D) Individuals with sickle cell disease; and

(E) Residents of a long-term care facility, of a facility described in 42 U.S.C. 1396d, or of another facility for which frequently abused drugs are dispensed for residents through a contract with a single pharmacy in accordance with 42 U.S.C. 1396w–3a(h)(2)(B); and

(F) Individuals admitted to an inpatient hospital facility. This exemption shall only apply to schedule II controlled substances provided or administered to the individual admitted to the inpatient hospital facility.

(b) PDMP requirements are in accordance with OAR 333-023-0800 to 333-023-0830.

(21) Providers of services outside of Oregon shall be enrolled as a provider if they comply with the requirements in OAR 410-120-1260 and under the following conditions:

(a) The provider is appropriately licensed or certified in the state in which the provider is located and meets standards for participation in the Medicaid program. Disenrollment or sanction from other states’ Medicaid programs or exclusion from any other federal or state health care program is a basis for disenrollment, termination, or suspension from participation as a provider in Oregon’s medical assistance programs;

(b) The provider bills only for services provided within the provider's scope of licensure or certification;

(c) For noncontiguous out-of-state providers, the services provided must be authorized in the manner required under OAR Ch 410 and Ch 309 rules specific to the service, OAR 410-120-1180 and these rule for out-of-state services:

(A) The services provided are for a specific Oregon Medicaid member who is temporarily outside Oregon or the contiguous area of Oregon;

(B) Services provided are for foster care or subsidized adoption children placed out of state; or

(C) The provider is seeking Medicare deductible or coinsurance coverage for Oregon Qualified Medicare Beneficiaries (QMB) members; or

(D) The services for which the provider bills are covered services under the Oregon Health Plan (OHP) and follow Authority requirements for prior authorization, when applicable.

(d) Facilities including but not restricted to hospitals, rehabilitative facilities, institutions for care of individuals with mental retardation, psychiatric hospitals, and residential care facilities shall be enrolled as providers only if the facility is enrolled as a Medicaid provider in the state in which the facility is located or is licensed as a facility provider of services by Oregon;

(e) Out-of-state providers may provide contracted services per OAR 410-120-1880; and

(f) Out-of-state entities seeking to enroll, or enrolled, as a billing provider shall register with the Secretary of State and the Department of Revenue to transact business in Oregon pursuant to ORS 63.701 and OAR 410-120-1260.

(g) The Authority shall enroll an out-of-state noncontiguous pharmacy as a provider only when enrollment is necessary to meet a need that cannot be met by an in-state pharmacy. The pharmacy is required to be licensed in the state where the member filled the prescription (i.e. state where medication is dispensed) and must be enrolled with the Authority as a Medicaid provider in order to submit claims or encounters to Authority. Identified needs include but are not limited to the following:

(A) Enrollment is necessary to reimburse an out-of-state pharmacy for services rendered to a member that travels out of Oregon and is unable to use a pharmacy licensed in Oregon. The out-of-state pharmacy must be licensed in the state where the services are rendered;

(B) Enrollment is necessary to ensure the Authority is the payer of last resort, OAR 410-120-1280, such as when a member’s TPL payer requires use of an out-of-state mail order pharmacy;

(C) Enrollment is necessary to ensure access to covered pharmacy services that are not otherwise generally available either through the Authority’s contracted mail order pharmacy or through enrolled in-state pharmacies; or

(D) Enrollment is necessary to ensure access to covered pharmacy services provided to members residing in a licensed in-state facility, such as a long-term care facility. The out-of-state pharmacy and the enrollment is limited to services provided to residents of the in-state facility.

(22) Termination of provider enrollment and the Authority assigned provider number:

(a) The provider may terminate enrollment at any time. The request shall be in writing and signed by the provider. The notice shall specify the Authority assigned provider number to be terminated and the effective date of termination. Termination or deactivation of the provider enrollment does not terminate any obligations of the provider for dates of services during which the enrollment was in effect;

(b) The Authority may deny enrollment, revalidation, or re-enrollment, or sanction and suspend or terminate a provider at any time including but not limited to any of the reasons listed in OAR410-120-1400; and

(c) Authority will send written notice to the provider when a provider’s application for enrollment, revalidation or re-enrollment is denied, enrollment is terminated or suspended, or a sanction is imposed by Authority under OAR 410-120-1400, regardless of whether the provider is continuously enrolled, or the provider number is active at the time notice is issued. Authority notice will state the effective date of the Action.

(23) A provider may appeal a termination, suspension or other sanction. If a provider’s enrollment, revalidation, or re-enrollment is denied, enrollment is suspended, terminated or any sanction is imposed by the Authority under this rule, the provider may request a contested case hearing pursuant to OAR 410-120-1400, 410-120-1460, 410-120-1600 and 410-120-1860.

(24) If a provider’s enrollment is suspended or terminated, the Authority may notify board of registration or licensure, federal or other state Medicaid agencies, MCEs and the National Practitioner Data Base of the finding(s) and the sanction(s) imposed.

(25) If a provider’s enrollment has been deactivated, terminated or suspended for any reason the provider must complete a new application for enrollment, including all required documentation, and submit it to the Authority. To re-enroll the provider, Authority review is contingent upon the risk-based screening in section (3) of this rule. A re-enrollment by Authority has the same requirements and process as a new enrollment.

(26) Authority may deny enrollment, revalidation or re-enrollment request (for encounter purposes) to an encounter only provider, or sanction and suspend or terminate an enrolled encounter only provider, for any of the reasons in OAR 410-120-1400:

(a) Authority will notify the encounter only provider and the MCE. Authority notice will state the effective date of the Action;

(b) Authority may recoup any overpayments in accordance with OAR Ch 410, Div. 120, CH 410 Div. 141, and the contract between the MCE and the Authority; and

(c) The MCE must adjust encounter claims in accordance with OAR 410-141-3570 and recoup overpayments from the provider in accordance with OAR 410-141-3510.

(27) The provision of health care services or items to Authority members is a voluntary action on the part of the provider. Providers are not required to serve all Authority members seeking service.

(28) Providers seeking to enroll in the Authority must be a provider type established in the State Plan as approved for Medicaid reimbursement.

[NOTE: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 34-2024, minor correction filed 01/18/2024, effective 01/18/2024
DMAP 85-2023, minor correction filed 12/05/2023, effective 12/05/2023
DMAP 84-2023, amend filed 11/30/2023, effective 12/01/2023
DMAP 21-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 34-2022, amend filed 02/17/2022, effective 02/17/2022
DMAP 40-2021, temporary amend filed 09/15/2021, effective 10/01/2021 through 03/13/2022
DMAP 39-2021, temporary suspends temporary DMAP 38-2021, filed 09/15/2021, effective 10/01/2021 through 03/13/2022
DMAP 38-2021, temporary amend filed 09/15/2021, effective 09/15/2021 through 03/13/2022
DMAP 78-2018, amend filed 06/27/2018, effective 07/01/2018
DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14
DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04
OMAP 62-2003, f. 9-8-03, cert. ef. 10-1-03
OMAP 42-2002, f. & cert. ef. 10-1-02
OMAP 9-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 10-1999, f. & cert. ef. 4-1-99
OMAP 20-1998, f. & cert ef. 7-1-98
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 31-1994, f. & cert. ef. 11-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0020, 410-120-0040 & 410-120-0060
HR 5-1992, f. & cert. ef. 1-16-92
HR 51-1991(Temp), f. 11-29-91, cert. ef. 12-1-91
HR 41-1991, f. & cert. ef. 10-1-91
HR 19-1990, f. & cert. ef. 7-9-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0063, 461-013-0075 & 461-013-0180
AFS 73-1989, f. & cert. ef. 12-7-89
AFS 38-1986, f. 4-29-86, cert. ef. 6-1-86
AFS 42-1983, f. 9-2-83, cert. ef. 10-1-83
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 57-1982, f. 6-28-82, cert. ef. 7-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 33-1981, f. 6-23-81, cert. ef. 7-1-81
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81, Renumbered from 461-013-0060
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1280 Billing

(1) A provider enrolled with the Authority or providing services to a client in a Managed Care Entity (MCE) under the Oregon Health Plan (OHP) may not seek payment from the client for any services covered by Medicaid fee-for-service or through contracted health care plans, except as authorized by the Authority under this rule.

(2) Identification of eligibility and third-party liability (TPL). The provider must:

(a) Verify the client’s eligibility for medical assistance and benefit package prior to rendering service pursuant to OAR 410-120-1140;

(b) Make “reasonable efforts” to identify third-party resources as described in section (10)(b) of this rule; and

(c) Ask the client at the point of service and verify prior to billing if the client has medical assistance, is applying for medical assistance, enrolled with an MCE or has other third-party liability.

(3) If a provider’s client is a medical assistance recipient, the provider must:

(a) Comply with the provisions in sections (10) through (12) of this rule regarding third-party resources;

(b) Submit a claim to the Authority or MCE, if no third-party resources are available or the provider has complied with section (2)(a) of this rule;

(c) Delay any billing or collection action against the client for ninety (90) calendar days from submitting the valid claim to the Authority or MCE, except as authorized in section (4) of this rule;

(d) If no payment is received from the Authority or MCE within ninety (90) calendar days from the date a valid claim (OAR 410-120-0000) was submitted:

(A) Verify the client’s eligibility for the date of service;

(B) If the individual was not eligible for medical assistance on the date of service, proceed with the provider’s normal billing and collection process; or

(C) If the individual was eligible for medical assistance on the date of service, and the provider does not have a completed agreement to pay form (OHP 3165, 3166, 4109), the provider is not allowed to bill the client, collect payment from the client, or assign an unpaid claim to a collection agency or similar entity pursuant to ORS 414.066, except as authorized by section (5) of this rule.

(4) For Medicaid covered services, the provider must not:

(a) Bill the Authority more than the provider's Usual Charge (OAR 410-120-0000) or the reimbursement specified in the applicable Authority program rules;

(b) Bill the client for missed appointments. A missed appointment is not considered to be a distinct Medicaid service by the federal government and as such is not billable to the client or the Authority;

(c) Bill the client for services or treatments that have been denied due to provider error, except as authorized under section (5) of this rule. Examples of provider error could be things such as required documentation not submitted for a prior authorization, or a prior authorization not submitted, or an error in the information or billing codes the provider listed on the claim.

(5) Providers may only bill a client or a financially responsible relative or representative of that client in the following situations:

(a) The client did not inform the provider of their Oregon Health plan I.D., MCE I.D. card, or third-party insurance card, or gave a name that did not match OHP I.D. at the time of or after a service was provided; therefore, the provider is now unable to bill the appropriate payer for reasons including but not limited to the lack of prior authorization, or because the time limit to submit the claim for payment to the appropriate payer has passed. The provider shall verify eligibility of the client at the time of service pursuant to OAR 410-120-1140 and prior to billing or collection pursuant to OAR 410-120-1280, and document each attempt to obtain coverage information prior to billing the client;

(b) The client became eligible for benefits retroactively but did not meet all of the other criteria required to receive the service;

(c) A third-party payer made payments directly to the client for services provided. The provider shall accept this payment from the third-party payer as payment in full;

(d) Citizenship Waived Medical (CWM) Benefits Package recipients prior to June 30, 2023, that received services that are not part of the CWM emergency only benefits, must have signed the provider-completed Agreement to Pay OHP form 3165, 3166 or 4109. CWM Benefits Package coverage, limitations, and billing guidance found in OAR 410-134-0005.

(e) The client has requested a continuation of benefits during the contested case hearing process, and the final decision was not in favor of the client. The client shall pay for any charges incurred for the denied service on or after the effective date on the Notice of Action or Notice of Appeal Resolution. The provider must complete the agreement to pay form OHP 3165 pursuant to section (5)(h) of this rule before providing these services to the client;

(f) The client has requested to privately pay for services denied as not meeting the prior authorization, HERC or other criteria. The provider shall provide to the client all required information for a non-covered service in this rule section (5)(h);

(g) The client has requested to privately pay for a covered service. In this situation, the provider may bill the client if the provider informs the client in advance of all the following:

(A) The client does not have to pay for the requested service because it is covered by the Oregon Health Plan; and

(B) the provider is not permitted to bill the client more than the amount the appropriate payer may be required to pay; and

(C) The estimated total cost of the covered service, including all related charges, that the client may have to pay if the client decides to privately pay, which cannot exceed the amount that the appropriate payer (Authority, or MCE, or third-party) may have to pay for the covered service; and

(D) That the client knowingly and voluntarily agrees to pay for the covered service; and

(E) The provider shall document in writing the date and time in the client’s medical record that:

(i) The provider gave the client or the client’s authorized representative the information described in section (5)(g)(A-C) of this rule; and

(ii) The client had an opportunity to ask questions, obtain additional information, and consult with the client's caseworker or client representative; and

(iii) The client agreed to privately pay for the covered service by signing an agreement to pay form (OHP 3165, 3166, 4109); and

(iv) The provider must give a copy of the signed and dated agreement to pay form (OHP 3165, 3166, 4109) to the client and keeps a copy of the form in the client’s medical record.

(F) A provider must not submit a claim for payment for covered services to the Authority, the client's MCE, or a third-party payer that is subject to the agreement.

(h) The service is a non-covered service by the Authority, or MCE (non-covered services include services denied under prior authorization. Refer to OAR 410-120-0000 for a definition of non-covered services). Before providing the non-covered service, the provider shall provide to the client of all of the following:

(A) The requested service is a non-covered service; and

(B) The estimated total cost of the non-covered service, including all related charges; and

(D) the provider documents in writing the date and time in the client’s record, indicating that:

(i) The provider gave the client or the client’s authorized representative the information described in OAR 410-120-1280 (5)(h)(A)-(C) of this rule; and

(ii) The client had an opportunity to ask questions, obtain additional information, and consult with the client's caseworker or client representative; and

(iii) The client agreed to privately pay for the non-covered service by signing an agreement to pay form (OHP 3165, 3166, 4109); and

(iv) The provider gives a copy of the signed and dated agreement to pay form (OHP 3165, 3166, 4109) to the client and keeps a copy of the form in the client’s medical record.

(E) the client must sign and date the provider-completed agreement to pay form (OHP 3165, 3166, or 4109);

(i) The completed agreement to pay form (OHP 3165, 3166, 4109) is valid only if the estimated fee for the service or good does not change and the service is scheduled within thirty (30) days of the client’s signature. The completed agreement to pay form (OHP 3165, 3166, 4109) is not transferrable to a different service or good. The agreement to pay form (OHP 3165, 3166, 4109) is not valid when this form is used by the provider as a generic agreement by the client to pay for unspecified non-covered services.

(ii) For some long-term services, such as labor and delivery, a single form can span the duration of the pregnancy.

(iii) Providers must make a copy of the completed agreement to pay form (OHP 3165, 3166 or 4109) available to the Authority or MCE upon request.

(i) For clients agreeing to pay for services under this rule section (5) who are limited English proficient, who are deaf, or hard of hearing, the provider shall provide translation or interpretation services before the client or a financially responsible relative or representative of that client signs the agreement to pay form (OHP 3165, 3166, 4109). This includes but is not limited to providing the following without limitation:

(A) Written documents in appropriate languages; and

(B) Interpreter services consistent with OAR 410-120-0001.

(6) Code set requirements:

(a) Federal Code Set requirements (45 CFR 162) apply to all Medicaid Code Set requirements, including the use of diagnostic or procedure codes for prior authorization, claims submissions, and payments. Code Set has the meaning set forth in 45 CFR 162.103, and it includes the codes and the descriptors of the codes, code guidelines, and parentheticals related to the code. Federal Code Set requirements are mandatory as part of the National Correct Coding Initiative (NCCI), and the Authority lacks any authority to delay or alter their application or effective dates as established by the U.S. Department of Health and Human Services;

(b) The Authority shall adhere to the Code Set requirements in 45 CFR 162.1000–162.1011;

(c) Periodically, the Authority shall update its provider rules and tables to conform to national codes. In the event of an alleged variation between an Authority-listed code and a national code, the Authority shall apply the national code in effect on the date of request or date of service. Providers billing the Authority shall use codes in the appropriate sequency and highest degree of specificity, append the appropriate modifiers, and indicate the appropriate and most specific place of services;

(d) Only codes with limitations or requiring prior authorization are noted in OAR. National Code Set issuance alone may not be construed as coverage or a covered service by the Authority;

(e) The Authority adopts by reference the National Code Set revisions, deletions, and additions issued and published by the American Medical Association (Current Procedural Terminology — CPT) and on the CMS website (Healthcare Common Procedural Coding System — HCPCS). This code adoption may not be construed as coverage or as a covered service by the Authority.

(7) Claims:

(a) Upon submission of a claim to the Authority for payment, the provider agrees that it has complied with all Division program rules. Submission of a claim, however, does not relieve the provider from the requirement of a signed provider agreement;

(b) A provider enrolled with the Division shall bill using the Authority assigned provider number, or the National Provider Identification (NPI) number , pursuant to OAR 410-120-1260;

(c) The provider may not bill the Division more than the provider's usual charge (see Definitions) or the reimbursement specified in the applicable Division program rules;

(d) Claims shall be submitted on the appropriate form as described in the individual Division program rules or electronically in a manner authorized in OAR Chapter 943, Division 120;

(e) Medicare shall send crossover claims to the Authority or contracted health plan after adjudication by Medicare. When billing Medicare as the primary payer, claims for all Medicaid/Medicare members shall include all applicable payer information (with Medicare as primary and Medicaid as secondary) so that Medicare can automatically transmit the correct Medicare payment, coinsurance, and deductible information to the Authority or MCE;

(f) Claims must be for services provided within the provider's licensure or certification as required by OAR Chapter 410 Division120 and program specific rules;

(g) Unless otherwise specified, claims shall be submitted after:

(A) Delivery of service; or

(B) Dispensing, shipment or mailing of the item.

(h) The provider shall submit true and accurate information when billing the Division. Use of a billing provider does not do away with the performing provider's responsibility for the truth and accuracy of submitted information;

(i) A claim is considered a valid claim only if it contains all data required for processing. See the appropriate provider rules and supplemental information for specific instructions and requirements;

(j) A provider or its contracted agency, including billing providers, may not submit or cause to be submitted:

(A) Any false claim for payment;

(B) Any claim altered in such a way as to result in a payment for a service that has already been paid;

(C) Any claim upon which payment has been made or is expected to be made by another source until after the other source has been billed with the exception of (10)(c)(A-D) of this rule. If the other source denies the claim or pays less than the Medicaid allowable amount, a claim may be submitted to the Division. Any amount paid by the other source must be clearly entered on the claim form and must include the appropriate Third Party Liability (TPL) Explanation Code;

(D) Any claim for furnishing specific care, items, or services that has not been provided.

(k) If an overpayment has been made by the Authority, the provider is required to do one of the following:

(A) Adjust the original claim to show the overpayment as a credit in the appropriate field:

(i) Submit an Individual Adjustment Request (OHP 1036); or

(ii) Adjust the claim on the Provider Web Portal at https://www.or-medicaid.gov;

(B) Refund the amount of the overpayment on any claim;

(D) If the overpayment occurred because of a payment from a third-party payer refer to section (10)(f) of this rule.

(L) 340B covered entities that bill Fee for Service (FFS) or a Coordinated Care Organization (CCO) shall follow OHA’s 340B policy in order to avoid “duplicate discounts”.

(8) Diagnosis code requirement:

(a) A primary diagnosis code is required on all claims, using the ICD-10-CM diagnosis code set, unless specifically excluded in individual Health System Division program rules;

(b) The primary diagnosis code shall be the code that most accurately describes the client’s condition;

(d) Hospitals shall follow national coding guidelines and bill using the seventh digit where applicable in accordance with methodology used in the Medicare Diagnosis Related Groups.

(9) Procedure code requirement:

(a) For claims requiring a procedure code the provider shall bill as instructed in the appropriate Division program rules and shall use the appropriate HIPAA procedure code set such as CPT, HCPCS, ICD-10-PCS, ADA CDT, NDC, established according to 45 CFR 162.1000 to 162.1011, which best describes the specific service or item provided;

(b) For claims that require the listing of a procedure code as a condition of payment, the code listed on the claim must be supported by the client’s medical record and must be the code that most accurately describes the services provided. All Providers, including Hospitals, shall follow national coding guidelines;

(c) When there is no appropriate descriptive procedure code to bill the Division, the provider shall use the code for “unlisted services.” Instructions on the specific use of unlisted services are contained in the individual provider rules. A complete and accurate description of the specific care, item, or service must be documented on the claim;

(d) Where there is one CPT, CDT, or HCPCS code that according to CPT, CDT, and HCPCS coding guidelines or standards describes an array of services, the provider shall bill the Division using that code rather than itemizing the services under multiple codes. Providers may not “unbundle” services in order to increase the payment.

(10) Third-Party Liability (TPL):

(a) Federal law requires that state Medicaid agencies take all reasonable measures to ensure that in most instances the Division shall be the payer of last resort;

(b) Providers shall make reasonable efforts to obtain payment first from other resources. For the purposes of this rule, “reasonable efforts” include determining the existence of insurance or other resources on each date of service by:

(A) Using an insurance database such as Electronic Verification System (EVS) available to the provider;

(B) Using the Automated Voice Response (AVR) or secure provider web portal on each date of service and at the time of billing;

(D) If the provider identifies from the client or other source third-party insurance that is unknown to the state or that is different from what is reported in one of the Division verification systems, the provider shall report the coverage to the Health Insurance Group (HIG) using the secure online form at www.reporttpl.org.

(c) Except as noted in section (10)(d)(A)-(E) of this rule, when third-party coverage is known to the provider prior to billing the Division, the provider shall:

(A) Bill all third-party insurance the client is covered by, which could include Personal Insurance Protection (PIP) or Workers Compensation if the claim is related to a personal injury; and

(B) Except for pharmacy claims billed through the Division’s point-of-sale system, the provider shall wait thirty (30) days from submission date of a clean claim and have not received payment from the third party; and

(D) Appeal a denied claim when the service is payable in whole or in part by an insurer.

(d) In accordance with federal regulations, the provider shall bill the TPL prior to billing the Division, except under the following circumstances:

(A) The covered health service is provided by an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID);

(B) The covered health service is provided by institutional services for the mentally and emotionally disturbed;

(D) Services are covered by a third-party insurer through an absent parent where the medical coverage is administratively or court ordered;

(E) When a negligent third party caused an injury or illness to a client, a provider may choose to bill the Liability Insurance (see Definitions), bill the liable third party, place a lien on a tort settlement or judgement, or bill the Division. The provider may not both place a lien against a settlement and bill the Division:

(i) The provider may withdraw their lien and bill the Division within twelve (12) months of the date of service; however, the provider shall accept the Division payment as payment in full;

(ii) The provider may not return the payment made by the Division in order to place a lien or to accept payment from a liability settlement, judgement, liability insurer, or other source.

(F) In the circumstances outlined in section (10)(d)(A)-(E) of this rule, the provider may choose to bill the primary insurance prior to billing the Division. Otherwise, the Division shall process the claim and, if applicable, pay the Division’s allowable rate for these services and seek reimbursement from the liable third-party insurance plan;

(G) In making the decision to bill the Division, the provider shall be cognizant of the possibility that the third-party payer may reimburse the service at a higher rate than the Division and that once the Division makes payment, no additional billing to the third party is permitted by the provider.

(e) The provider may bill the Division directly for services that are never covered by Medicare or another insurer on the appropriate form identified in the relevant provider rules. Documentation shall be on file in the provider's records indicating this is a non-covered service for purposes of Third-Party Resources. See the individual provider rules for further information on services that shall be billed to Medicare first;

(f) In the case of known third-party coverage, a provider may bill the Division if payment from the third-party coverage is not received within thirty (30) days. If a payment is received from the third-party coverage after receiving the Division payment, the provider shall do the following within thirty (30) days of receiving the payment:

(A) Submit an Individual Adjustment Request (OHP 1036) that shows the amount of the third-party payment as a credit in the appropriate field; or

(B) Submit a claim adjustment online at https://www.or-medicaid.gov/ProdPortal/ that shows the amount of the third-party payment as a credit in the appropriate field; or

(C) Refund the amount paid by the Division. The amount refunded shall be the lesser of the third-party payment or the amount paid by the Division. The check to repay the Division shall include the reason the payment is being made and either

(i) An Individual Adjustment Request that identifies the original claim, name and number of the client, date of service, and items or services for which the repayment is made; or

(ii) A copy of the Remittance Advice showing the original Division payment.

(D) Failure to submit the Individual Adjustment Requests within thirty (30) days of receipt of the third-party payment or to refund the Division payment is considered concealment of material facts and is grounds for recovery and sanction;

(E) Any provider who accepts payment from a client or client’s representative and is subsequently paid for the service by the Division shall reimburse the client or their representative the full amount of their payment.

(g) If the third-party coverage is not known by the Division or the provider at the time the Division makes payment, a provider may not return the Division payment in order to bill the third-party coverage if the third-party coverage becomes known after the Division payment;

(h) The Division may make a claim against any third-party payer after making payment to the provider of service. The Division may pursue alternate resources following payment if it deems this a more efficient approach. Pursuing alternate resources includes but is not limited to requesting the provider to bill the third party and to refund the Division in accordance with this rule;

(i) For services provided to a Medicare and Medicaid dual eligible client, the Division may request the provider to submit a claim for Medicare payment, except as noted in OAR 410-141-3565, and the provider shall honor that request. Claims submitted to Medicare shall include the Medicaid information necessary to enable electronic crossover to the Authority or contracted health plan. Under federal regulation, a provider may not charge a beneficiary (or the state as the beneficiary's subrogee) for services for which a provider failed to file a timely claim (42 CFR 424) with Medicare despite being requested to do so;

(j) If Medicare is the primary payer and Medicare denies payment, Medicare appeals shall be timely pursued, and Medicare denial must be obtained prior to submitting the claim for payment to the Division. Medicare denial on the basis of failure to submit a timely appeal may result in the Division reducing from the amount of the claim any amount the Division determines could have been paid by Medicare.

(11) Full use of alternate resources:

(a) The Division shall generally make payment only when other resources are not available for the client's medical needs. Full use must be made of reasonable alternate resources in the local community;

(b) Except as provided in section (12) of this rule, alternate resources may be available:

(A) Under a federal or state worker's compensation law or plan;

(B) For items or services furnished by reason of membership in a prepayment plan;

(C) For items or services provided or paid for directly or indirectly by a health insurance plan or as health benefits of a governmental entity such as:

(i) Armed Forces Retirees and Dependents Act (CHAMPVA);

(ii) Armed Forces Active Duty and Dependents Military Medical Benefits Act (CHAMPUS); or

(iii) Medicare Parts A and B.

(D) To residents of another state under that state's Title XIX or state funded medical assistance programs; or

(E) Through other reasonably available resources.

(12) Exceptions:

(a) Indian Health Services or Tribal Health Facilities. Pursuant to 42 CFR 136.61 subpart G and the Memorandum of Agreement in OAR 410-146-0020, Indian Health Services facilities and Tribal facilities operating under Public Law 93, Section 638 agreement are payers of last resort and are not considered an alternate resource or TPL;

(b) Veterans Administration. Veterans who are also eligible for Medicaid benefits are encouraged to utilize Veterans’ Administration facilities whenever possible. Veterans’ benefits are prioritized for service-related conditions and as such are not considered an alternate or TPL.

(13) Table 120-1280 – TPR codes.

(14) Table – OHP Client Agreement to Pay form for Health Services, OHP 3165, 3166 or 4109.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.066
DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024
DMAP 93-2024, amend filed 05/24/2024, effective 05/24/2024
DMAP 41-2024, amend filed 02/06/2024, effective 02/06/2024
DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 28-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 21-2021, amend filed 06/03/2021, effective 06/03/2021
DMAP 27-2020, amend filed 06/16/2020, effective 06/17/2020
DMAP 2-2020, temporary amend filed 01/14/2020, effective 01/15/2020 through 07/11/2020
DMAP 62-2017, amend filed 12/28/2017, effective 01/01/2018
DMAP 53-2016, f. 8-26-16, cert. ef. 9-1-16
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 40-2015, f. & cert. ef. 7-1-15
DMAP 61-2013, f. 10-31-13, cert. ef. 11-1-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 67-2005, f. 12-21-05, cert. ef. 1-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 73-2002, f. 12-24-02, cert. ef. 1-1-03
OMAP 42-2002, f. & cert. ef. 10-1-02
OMAP 23-2002, f. 6-14-02 cert. ef. 8-1-02
OMAP 30-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 31-1999, f. & cert. ef. 10-1-99
OMAP 10-1999, f. & cert. ef. 4-10-99
OMAP 20-1998, f. & cert. ef. 7-1-98
HR 21-1997, f. & cert. ef. 10-1-97
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 31-1994, f. & cert. ef. 11-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0040, 410-120-0260, 410-120-0280, 410-120-0300 & 410-120-0320
HR 41-1991, f. & cert. ef. 10-1-91
HR 19-1990, f. & cert. ef. 7-9-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0140, 461-013-0150, 461-013-0175 & 461-013-0180
AFS 38-1988, f. 5-17-88, cert. ef. 6-1-88
AFS 14-1987, f. 5-31-87, cert. ef. 4-1-87
AFS 57-1986, f. 7-25-86, cert. ef. 8-1-86
AFS 43-1986, f. 6-13-86, cert. ef. 7-1-86
AFS 33-1986, f. 4-11-86, cert. ef. 6-1-86
AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85
AFS 36-1984, f. & cert. ef. 8-20-84
AFS 6-1984(Temp), f. 2-28-84, cert. ef. 3-1-84
AFS 45-1983, f. 9-19-83, cert. ef. 10-1-83
AFS 42-1983, f. 9-2-83, cert. ef. 10-1-83
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81, Renumbered from 461-013-0050, 461-013-0060, 461-013-0090 & 461-013-0020
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1285 Recoupment and Data Sharing with Third-Party Insurers

(1) The Oregon Health Authority (Authority) delegates to the Department of Human Services (Department), Office of Payment Accuracy and Recovery (OPAR) (for OPAR see Administrative Rules chapter 407 division 120, or chapter 943 division 120) authority to administer Third-Party Liability programs required by federal law to reduce medical expenditures. This includes the following programs:

(a) The Data Match Unit;

(b) The Health Insurance Group;

(d) The Personal Injury Liens Unit.

(2) For this rule, an “insurer” means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third-party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or other party that is by statute, contract, or agreement legally responsible for payment of a claim for a health care item or service.

(3) “OPAR” means the Office of Payment Accuracy and Recovery, Department of Human Services, and subunits. (For OPAR see Administrative Rules chapter 407 division 120, or see chapter 943 division 120).

(4) For this rule “subscriber” means an individual who is eligible for coverage on their behalf and not because of dependent status.

(5) An insurer shall provide to OPAR, a CCO, or a Managed Care Organization, upon request, within 30 calendar days, the following information:

(a) The period during which a recipient, a spouse, partner or dependents are covered by the insurer;

(b) The nature of coverage that is provided by the insurer; for example, medical, prescription drug, dental, vision, motor vehicle personal injury protection, or workers compensation;

(d) The name of the subscriber, if any, and the date of birth and social security number;

(e) The amount of any copay, coinsurance, or deductible required by the insurer.

(6) An insurer may not deny a claim submitted by OPAR, a managed care organization, or a CCO, based on the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim if:

(a) The claim is submitted within the three-year period beginning on the date on which the health care item or service was furnished; and

(b) Any action to enforce the claim is commenced within six years of submission of the claim.

(7) If an insurer denies a claim or does not pay the claim in full, the insurer shall provide a detailed explanation for its action, including citation to applicable contractual or statutory authority for the action. If the insurer cites a contractual provision, the insurer shall provide a copy of the applicable contractual provision on request.

(8) An insurer, when requested by OPAR, shall provide OPAR an electronic file of all insured or subscribed individuals residing in Oregon to assist OPAR to do a data match with recipient records to determine if any Medicaid recipient has coverage through the insurer. The electronic file shall be delivered to OPAR every 30 days, unless otherwise agreed. The Authority may enter into a trading partner agreement with the insurer to permit the exchange of information via “ASC X 12N 270/271 Health Benefit Inquiry and Response” transactions or other HIPAA compliant secure transaction methods in the event 270/271 transactions are not available. The insurer shall include the following information in the electronic file:

(a) The period during which a subscriber or insured, the spouse, partner or dependents are covered by the plan;

(b) The nature of coverage that is provided by the plan; for example, medical, prescription, dental, vision, or automotive personal injury protection, and workers compensation;

(d) The name of the subscriber, if any, and date of birth and social security number;

(e) The amount of any copay, coinsurance, or deductible required by the insurer.

(9) An insurer may not charge a fee for sharing data with the Authority, OPAR, a managed care organization, or CCO or for processing claims submitted by OPAR, a managed care organization, or a CCO.

(10) In the event a claim submitted to an insurer by OPAR, a managed care organization, or a CCO is paid all or in part to a third party, the insurer shall within 14 calendar days give the name and address of the payee, the check number, date and amount of the check or electronic payment, and a copy of the check or electronic payment to the claimant on request.

History

Statutory/Other Authority: ORS 413.042, 413.085, 414.685, 42 USC § 1396a(a)(25) & (45), 42 USC § 1396k, 42 CFR §§ 433.135 to 433.139, 42 CFR §§ 433.145 to 433.146 & Oregon Medicaid State Plan Attachment 4.22-A(3) & (7)
Statutes/Other Implemented: ORS 414.685, 659.830 & 743B.470
DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024
DMAP 22-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 48-2019, adopt filed 11/20/2019, effective 01/01/2020

Or. Admin. R. 410-120-1295 Temporary rule language in effect until 01/16/2027. Non-Participating Provider

(1) For purposes of this rule, a provider enrolled with the Health Systems Division (Division) that does not have a contract with a Division-contracted Managed Care Entity (MCE) is referred to as a non-participating provider.

(2) For services covered by the CCO or PHP, a non-participating provider, other than a hospital governed by (3) and (4) of this rule, must accept from the Division-contracted MCE, as payment in full, the amount that the provider would be paid from the Division if the client was fee-for-service (FFS).

(3) For covered services provided on and after October 1, 2011, the Division-contracted MCE that does not have a contract with a hospital, is required to reimburse, and hospitals are required to accept as payment in full, the following reimbursement:

(a) Non-participating Type A and Type B hospital: The MCE shall reimburse a non-participating Type A and Type B hospital fully for the cost of covered services based on the cost-to-charge ratio used for each hospital in setting the global payments to the MCE for the contract period;

(b) Hospitals (not designated as a rural access or Type A and Type B hospital) including Child/Adolescent Psychiatric units in a hospital: As specified in ORS 414.743, the MCE shall reimburse inpatient and outpatient services using a Medicare payment methodology at a specified percentage point less than the percentage of Medicare costs used by the Oregon Health Authority (Authority) when calculating the base hospital capitation payment to the MCE excluding any supplemental payments:

(A) Effective for services on or after October 1, 2011, for a hospital providing 10 percent or more of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 64 percent;

(B) Effective for services on or after October 1, 2011, for a hospital providing less than 10 percent of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 66 percent;

(C) Effective for services on or after January 1, 2020 for a hospital providing 10 percent or more of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 76 percent;

(D) Effective for services on or after January 1, 2020 for a hospital providing less than 10 percent of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 78 percent;

(E) Effective for services on or after January 1, 2023 but before January 1, 2024.

(i) For a hospital providing 10 percent or more of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 81 percent; and

(ii) For a hospital providing less than 10 percent of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 83 percent.

(c) Effective for services on or after January 1, 2025, inpatient psychiatric adult and pediatric services shall be reimbursed using the DRG and outlier methodology outlined in OAR 410-125-0141 (10) and (11);

(d) For Maternity Services effective on or after January 1, 2026 but before January 1, 2027:

(A) For hospital providing 10 percent or more of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 100 percent; and

(B) For a hospital providing less than 10 percent of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 102 percent.

(4) A non-participating hospital must notify the MCE within two (2) business days of an MCE patient admission when the MCE is the primary payer. Failure to notify does not, in and of itself, result in denial for payment. The CCO or FCHP is required to review the hospital claim for:

(a) Medical appropriateness;

(b) Compliance with emergency admission or prior authorization policies;

(d) The MCE contract and the Division’s administrative rules.

(5) After notification from the non-participating hospital, the MCE may:

(a) Arrange for a transfer to a contracted facility, if the patient is medically stable and the MCE has secured another facility to accept the patient;

(b) Perform concurrent review; and/or

(6) In the event of a disagreement between the MCE and hospital, the provider may appeal the decision by asking for an administrative review as specified in OAR 410-120-1580.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065, 414.025 & 414.743
DMAP 31-2026, temporary amend filed 07/21/2026, effective 07/21/2026 through 01/16/2027
DMAP 22-2026, amend filed 06/05/2026, effective 06/05/2026
DMAP 103-2025, temporary amend filed 12/31/2025, effective 01/01/2026 through 06/29/2026
DMAP 96-2025, temporary amend filed 12/29/2025, effective 01/01/2026 through 06/29/2026
DMAP 90-2025, amend filed 12/17/2025, effective 12/17/2025
DMAP 59-2025, temporary amend filed 07/30/2025, effective 08/01/2025 through 01/27/2026
DMAP 55-2025, amend filed 06/26/2025, effective 06/29/2025
DMAP 150-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 93-2022, amend filed 12/27/2022, effective 01/01/2023
DMAP 77-2022, minor correction filed 09/30/2022, effective 09/30/2022
DMAP 51-2019, amend filed 12/12/2019, effective 01/01/2020
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 15-2012, f. & cert. ef. 3-22-12
DMAP 30-2011(Temp), f. & cert. ef. 10-20-11 thru 3-25-12
DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 4-2010, f. & cert. ef. 3-26-10
DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 35-2009(Temp), f. & cert. ef. 12-4-09 thru 3-25-10
DMAP 28-2009(Temp), f. 9-11-09, cert. ef. 10-1-09 thru 3-25-10
DMAP 24-2007, f. 12-11-07 cert. ef. 1-1-08
DMAP 2-2007, f. & cert. ef. 4-5-07
OMAP 42-2006(Temp), f. 12-15-06, cert. ef. 1-1-07 thru 6-29-07
OMAP 28-2006, f. 6-22-06, cert. ef. 6-23-06
OMAP 72-2005(Temp), f. 12-29-05, cert. ef. 1-1-06 thru 6-28-06
OMAP 66-2005(Temp), f. 12-13-05, cert. ef. 1-1-06 thru 6-28-06
OMAP 63-2005, f. 11-29-05, cert. ef. 1-1-06
OMAP 49-2005(Temp), f. 9-15-05, cert. ef. 10-1-05 thru 3-15-06
OMAP 35 2005, f. 7-21-05, cert. ef. 7-22-05
OMAP 33-2005, f. 6-21-05, cert. ef. 7-1-05
OMAP 4-2005(Temp), f. & cert. ef. 2-9-05 thru 7-1-05
OMAP 75-2004(Temp), f. 9-30-04, cert. ef. 10-1-04 thru 3-15-05
OMAP 33-2004, f. 5-26-04, cert. ef. 6-1-04
OMAP 23-2004(Temp), f. & cert. ef. 3-23-04 thru 8-15-04
OMAP 22-2004, f. & cert. ef. 3-22-04
OMAP 10-2001, f. 3-30-01, cert. ef. 4-1-01

Or. Admin. R. 410-120-1300 Timely Submission of Claims

(1) In order to be reimbursed for services rendered, providers must comply with the following:

(a) Medicaid fee-for-service only claims must be filed within 12 months of the date of service. The date of service for an inpatient hospital stay is considered the date of discharge;

(b) Claims for recipients that have Medicare and Medicaid coverage must be filed with the Medicare fiscal intermediary within 12 months of the date of service to meet the Division’s timely filing rule;

(c) Claims that fail to cross over electronically from Medicare must be submitted hard copy to the Division within six months from the date on the Medicare Explanation of Medicare Benefits (EOMB), provided they are filed with Medicare within one year from the date of service;

(d) Claims for CCO enrolled members must comply with Oregon Administrative Rule 410-141-3565.

(2) A claim submitted within 12 months of the date of service but is denied may be resubmitted within 18 months of the date of service. These claims must be submitted to the Health Systems Division (Division) at the address listed in the provider contacts document. The provider must present documentation acceptable to the Division verifying the claim was originally submitted within 12 months of the date of service, unless otherwise stated in individual provider rules. Acceptable documentation is:

(a) A remittance advice from the Division that shows the claim was submitted before the claim was one year old;

(b) A copy of a billing record or ledger showing dates of submission to the Division.

(3) Exceptions to the 12-month requirement that may be submitted to the Division are as follows:

(a) When the Department, Division, or the client's branch office makes an error that causes the provider not to be able to bill within 12 months of the date of service, the claim may be filed up to six months after the error is discovered. The Division must confirm the error;

(b) When a court or an Administrative Law Judge orders the Division to make payment;

(c) When the Division determines a client is retroactively eligible for Division medical coverage and more than 12 months passes between the date of service and the determination of the client's eligibility.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 23-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 78-2018, amend filed 06/27/2018, effective 07/01/2018
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 20-1998, f. & cert. ef. 7-1-98
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 31-1994, f. & cert. ef. 11-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0340
HR 41-1991, f. & cert. ef. 10-1-91
HR 19-1990, f. & cert. ef. 7-9-90
HR 2-1990, f. 12-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0145
AFS 55-1987, f. 10-29-87, cert. ef. 11-1-87
AFS 17-1985, f. 3-27-85, cert. ef. 5-1-85
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 103-1982, f. & cert. ef. 11-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
Renumbered from 461-013-0080, AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81
AFS 46-1980, f. & cert. ef. 8-1-80
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-198-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1320 Authorization of Payment

(1) Some services or items covered by the Oregon Health Authority require authorization before the service can be provided. See the appropriate Oregon Health Authority rules for information on services requiring authorization and the process to be followed to obtain authorization, such as "OAR 410-120-1360 Requirements for Financial, Clinical and Other Records.”

(2) Documentation submitted when requesting authorization must support the medical justification for the service. A complete request is one that contains all necessary documentation and meets any other requirements as described in the appropriate Oregon Health Authority rules.

(3) The Oregon Health Authority shall authorize for the level of care or type of service that meets the client's medical need. Only services which are medically appropriate and for which the required documentation has been supplied may be authorized. The authorizing agency may request additional information from the provider to determine medical appropriateness or appropriateness of the service.

(4) The Oregon Health Authority may not consider quality of life in general measures (e.g., Quality Adjusted Life Years or QALYs), either directly or by considering a source that relies on a quality of life in general measure, in establishing utilization controls (e.g., prior authorization) or otherwise making benefit determinations. “Quality of life in general measure” means an assessment of the value, effectiveness or cost-effectiveness of a treatment that gives greater value to a year of life lived in perfect health than the value given to a year of life lived in less than perfect health. “Quality of life in general measure” does not mean an assessment of the value, effectiveness or cost-effectiveness of a treatment during a clinical trial in which a study participant is asked to rate the participant’s physical function, pain, general health, vitality, social functions or other similar domains (e.g., the Short Form Health Survey or SF-36).

(5) The Oregon Health Authority may not make payment for authorized services under the following circumstances:

(a) The client was not eligible at the time services were provided. The provider is responsible for checking the client's eligibility each time services are provided;

(b) The provider cannot produce appropriate documentation to support medical appropriateness, or the appropriate documentation was not submitted to the authorizing agency;

(c) The service has not been adequately documented (see OAR 410-120-1360, Requirements for Financial, Clinical and Other Records).The documentation in the provider's files is not adequate to determine the type, medical appropriateness, or quantity of services provided and required documentation is not in the provider's files;

(d) The services billed or provided are not consistent with the information submitted when authorization was requested or the services provided are determined retrospectively not to be medically appropriate;

(e) The services billed are not consistent with those provided;

(f) The services were not provided within the timeframe specified on the authorization of payment document;

(g) The services were not authorized or provided in compliance with the rules in these General Rules and in the appropriate provider rules.

(6) Retroactive authorizations:

(a) Authorization for payment may be given for a past date of service if:

(A) The client was made retroactively eligible or was retroactively disenrolled from a CCO or PHP on the date of service; and

(B) The services provided meet all other criteria and Oregon Administrative Rules, and;

(b) Any requests for authorization after ninety (90) days from date of service require documentation from the Provider that authorization could not have been obtained within ninety (90) days of the date of service.

(7) Payment authorization is valid for the time period specified on the authorization notice, but not to exceed twelve (12) months, unless the Client’s benefit package no longer covers the service, in which case the authorization will terminate on the date coverage ends.

(8) When clients have other health care coverage (third-party resources, or TPR), the Oregon Health Authority only requires payment authorization for the services that TPR does not cover. Examples include:

(a) When Medicare is the primary payer for a service, no payment authorization from the Oregon Health Authority is required, unless specified in the appropriate Oregon Health Authority program rules;

(b) When other TPR is primary, such as Blue Cross, CHAMPUS, etc., the Oregon Health Authority requires payment authorization when the other insurer or resource does not cover the service or reimburses less than the Oregon Health Authority rate.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024
DMAP 110-2024, minor correction filed 07/10/2024, effective 07/10/2024
DMAP 108-2024, minor correction filed 06/20/2024, effective 06/20/2024
DMAP 24-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 24-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 62-2003, f. 9-8-03, cert. ef. 10-1-03
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 31-1999, f. & cert. ef. 10-1-99
OMAP 10-1999, f. & cert. ef. 4-1-99
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 6-1996, f. 5-31-96, cert. ef. 6-1-96
HR 40-1994, f. 12-30-94, cert. ef. 1-1-95
HR 22-1994, f. 5-31-94, cert. ef. 6-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0180
HR 41-1991, f. & cert. ef. 10-1-91
HR 32-1990, f. 9-24-90, cert. ef. 10-1-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0106 & 461-013-0180
AFS 38-1986, f. 4-29-86, cert. ef. 16-1-86
AFS 37-1984, f. 8-30-84, cert. ef. 9-1-84
AFS 11-1984(Temp), f. 3-14-84, cert. ef. 3-15-84
AFS 7-1984(Temp), f. 2-28-84, cert. ef. 3-15-84
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
Renumbered from 461-013-0041, AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 33-1981, f. 6-23-81, cert. ef. 7-1-81
AFS 13-1981, f. 2-27-81, cert. ef. 3-1-81
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81, Renumbered from 461-013-0060
AFS 14-1979, f. 6-29-79, cert. ef. 7-1-79
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1340 Payment

(1) The Division shall make payment only to the enrolled provider (see OAR 410-120-1260) who actually performs the service or to the provider's enrolled billing provider for covered services rendered to eligible clients.

(2) Division reimbursement for services may be subject to review prior to reimbursement.

(3) The Division sets fee-for-service (FFS) payment rates for the billed services or items. The FFS payment rates are the Division’s maximum allowable rates for billed services or items.

(4) The Division reimburses providers for billed services or items at the lesser of:

(a) The amount billed;

(b) The Division’s FFS payment rate in effect on the date of service; or

(5) The amount billed may not exceed the provider’s “usual charge” (see definitions OAR 410-120-0000).

(6) The Division’s maximum allowable rate setting process uses the following methodology for:

(a) Relative Value Unit (RVU) weight-based rates. The Division updates all CPT/HCPCS codes assigned an RVU weight effective January 1 of each year, based on the annual RVU updates published in the Federal Register:

(A) The Division applies RVU weights as follows:

(i) The Non-Facility Total RVU weight, to professional services not typically performed in a facility;

(ii) The Facility Total RVU weight, to professional services typically performed in a facility.

(B) The Division applies the following conversion factors:

(i) $40.79 for labor and delivery codes (59400-59622);

(ii) $38.76 for neonatal intensive care and pediatric intensive care professional service codes (99464-99465, 99468-99480);

(iii) $28.50 for Oregon primary care providers. A current list of primary care CPT, HCPCs, and provider types and specialties (“Oregon Primary Care Providers and Procedure Codes”) is available at http://www.oregon.gov/OHA/HSD/OHP/Pages/Providers.aspx;

(iv) $27.11 for all remaining RVU weight-based CPT/HCPCS codes.

(i) (Work RVU) X (Work GPCI) + (Practice Expense RVU) X (Practice GPCI) + (Malpractice RVU) X (Malpractice GPCI). The formula used to create the statewide GPCI is (3*(Portland GPCI) + 33* (Rest of State GPCI))/36 = GPCI.

(ii) The sum in paragraph (C)(i) is multiplied by the applicable conversion factor in section (B) to calculate the rate;

(b) Non-RVU-weight-based rates:

(A) $21.12 is the base rate for anesthesia service codes 00100-01996. The rate is based on per unit of service;

(B) Clinical lab codes are 80 percent of the Medicare clinical lab fee schedule effective on the date of service;

(C) All approved Ambulatory Surgical Center procedures are 80 percent of the Medicare fee schedule effective on the date of service;

(D) Physician-administered drugs billed under a HCPCS code are 100 percent of the Medicare rate;

(i) When no Medicare rate is available, the rate is based upon the Wholesale Acquisition Cost (WAC) provided by First Data Bank;

(ii) If no WAC is available, then the rate is the Acquisition Cost. These rates may change periodically based on drug costs;

(c) All procedures used for vision materials and supplies are contracted rates that include acquisition cost plus shipping and handling;

(d) Individual provider rules may specify rates for particular services or items.

(7) The Division reimburses inpatient hospital services under the DRG methodology, unless specified otherwise in the Hospital Services program administrative rules (chapter 410, division 125). Reimbursement for services, including claims paid at DRG rates, may not exceed any upper limits established by federal regulation.

(8) The Division reimburses all out-of-state hospital services at Oregon DRG or FFS rates as published in the Hospital Services program rules (chapter 410, division 125) unless the hospital has a contract or service agreement with the Division to provide highly specialized services.

(9) Payment rates for in-home services provided through Oregon Department of Human Services (Department) Aging and People with Disabilities (APD) may not exceed the costs of nursing facility services unless the criteria in OAR 411-027-0020 have been met.

(10) For services provided by out-of-state institutions and facilities such as skilled nursing care facilities, psychiatric facilities and rehabilitative care facilities, the Division sets rates that are:

(a) Consistent with the rate for similar services provided in Oregon; and

(b) The lesser of the rate paid to the most similar licensed Oregon facility or the rate paid by the other state’s Medicaid program; or

(11) The Division may not make payment on the following claims:

(a) Assigned, sold or otherwise transferred claims; or

(b) Claims where the billing provider, billing agent, or billing service receives a percentage of the amount billed, amount collected or payment authorized. This includes, but is not limited to, claims transferred to a collection agency or individual who advances money to a provider for accounts receivable.

(12) Nursing facility payments:

(a) The Division may not make a separate payment to a nursing facility or other provider for services included in the nursing facility's all-inclusive rate (OAR 411-070-0085).

(b) The following services are not in the all-inclusive rate and may be reimbursed separately:

(A) Legend drugs, biologicals and hyperalimentation drugs and supplies, and enteral nutritional formula as addressed in the Pharmaceutical Services program administrative rules (chapter 410, division 121) and Home Enteral/Parenteral Nutrition and IV Services program administrative rules (chapter 410, division 148);

(B) Physical therapy, speech therapy, and occupational therapy provided by a non-employee of the nursing facility within the appropriate program administrative rules (chapter 410, division 129 and 131);

(C) Continuous oxygen that exceeds 1,000 liters per day by lease of a concentrator or concentrators as addressed in the Durable Medical Equipment, Prosthetics, Orthotics and Supplies program administrative rules (chapter 410, division 122);

(D) Influenza immunization serum as described in the Pharmaceutical Services program administrative rules (chapter 410, division 121);

(E) Podiatry services provided under the rules in the Medical-Surgical Services program administrative rules (chapter 410, division 130);

(F) Medical services provided by a physician or other provider of medical services, such as radiology and laboratory, as outlined in the Medical-Surgical Services program rules (chapter 410, division 130);

(G) Certain custom fitted or specialized equipment as specified in the Durable Medical Equipment, Prosthetics, Orthotics and Supplies program administrative rules (chapter 410, division 122).

(13) The Division reimburses hospice services based on CMS Core-Based Statistical Areas (CBSAs). A separate payment may not be made for services included in the core package of services as outlined in chapter 410, division 142.

(14) For payment for Division clients with Medicare and full Medicaid:

(a) The Division limits payment to the Medicaid allowed amount, less the Medicare payment, up to the Medicare co-insurance and deductible, whichever is less. The Division’s payment may not exceed the co-insurance and deductible amounts due;

(b) The Division pays the allowable rate for covered services that are not covered by Medicare.

(15) For clients with third-party resources (TPR), the Division pays the allowed rate less the TPR payment but not to exceed the billed amount.

(16) The Division payments including contracted Managed Care Entity (MCE) payments, unless in error, constitute payment in full, except in limited instances involving allowable spend-down. For the Division, payment in full includes:

(a) Zero payments for claims when a third party or other resource has paid an amount equivalent to or exceeding Division allowable payment; and

(b) Denials of payment for failure to submit a claim in a timely manner, failure to obtain payment authorization in a timely and appropriate manner, or failure to follow other required procedures identified in the individual provider rules.

(17) Payment by the Division does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit a claim before or after the payment. Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the service was not provided in accordance with applicable rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.033, 414.065, 414.095, 414.727, 414.728, 414.742 & 414.743
DMAP 51-2025, amend filed 06/24/2025, effective 06/25/2025
DMAP 115-2024, amend filed 07/31/2024, effective 08/01/2024
DMAP 93-2024, amend filed 05/24/2024, effective 05/24/2024
DMAP 100-2023, minor correction filed 12/29/2023, effective 12/29/2023
DMAP 84-2023, amend filed 11/30/2023, effective 12/01/2023
DMAP 40-2022, amend filed 03/25/2022, effective 03/25/2022
DMAP 26-2020, amend filed 06/16/2020, effective 06/17/2020
DMAP 10-2020, temporary amend filed 03/18/2020, effective 03/18/2020 through 09/13/2020
DMAP 33-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 27-2018, amend filed 05/02/2018, effective 05/02/2018
DMAP 14-2018, temporary amend filed 03/08/2018, effective 03/08/2018 through 09/03/2018
DMAP 50-2017, amend filed 12/05/2017, effective 01/01/2018
DMAP 35-2017, f. 9-12-17, cert. ef. 9-15-17
DMAP 16-2017(Temp), f. 5-23-17, cert. ef. 5-26-17 thru 11-21-17
DMAP 9-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 86-2015(Temp), f. 12-24-15, cert. ef. 1-1-16 thru 6-28-16
DMAP 11-2015, f. & cert. ef. 3-4-15
DMAP 83-2014(Temp), f. 12-23-14, cert. ef. 1-1-15 thru 6-29-15
DMAP 24-2014, f. & cert. ef. 4-4-14
DMAP 71-2013, f. & cert. ef. 12-27-13
DMAP 49-2013, f. & cert. ef. 9-25-13
DMAP 14-2013(Temp), f. & cert. ef. 3-29-13 thru 9-25-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 41-2012(Temp), f. 8-22-12, cert. ef. 9-1-12 thru 2-28-13
DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12
DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 35-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 24-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 62-2003, f. 9-8-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 10-1999, f. & cert. ef. 4-1-99
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 2-1994, f. & cert. ef. 2-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0040, 410-120-0220, 410-120-0200, 410-120-0240 & 410-120-0320
HR 41-1991, f. & cert. ef. 10-1-91
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0081, 461-013-0085, 461-013-0175 & 461-013-0180
AFS 50-1985, f. 8-16-85, cert. ef. 9-1-85
AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
Renumbered from 461-013-0060, AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
Renumbered from 461-013-0061, AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81
Renumbered from 461-013-0061, PWC 833, f. 3-18-77, cert. ef. 4-1-77
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-784

Or. Admin. R. 410-120-1350 Buying-Up

(1) Providers are not permitted to bill and accept payment from the Division or a managed care plan for a covered service:

(a) When a non-covered service has been provided; and

(b) Additional payment is sought or accepted from the Division client.

(2) Examples include, but are not limited to, charging the client an additional payment to obtain a gold crown (non covered) instead of the stainless steel crown (covered) or charging an additional client payment to obtain eyeglass frames not on the Division or managed care plan contract.

(3) If a client wants to purchase a non-covered service or item, the client must be responsible for full payment. The Division or managed care plan payment for a covered service cannot be credited toward the non-covered service.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 27-2023, minor correction filed 04/27/2023, effective 04/27/2023
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-120-1360 Requirements for Financial, Clinical and Other Records

(1) The Authority shall analyze, monitor, audit, and verify the accuracy and appropriateness of payment, utilization of services, medical necessity, medical appropriateness, quality of care, and access to care of the Medical Assistance Programs and the Children's Health Insurance Program.

(2) The provider or the provider's designated billing service or other entity responsible for the maintenance of financial, clinical, and other records shall develop and maintain adequate financial and clinical records and other documentation that supports the specific care, items, or services for which payment has been requested. Payment shall be made only for services that are adequately documented. Documentation shall be completed before the service is billed to the Division and meet the following requirements:

(a) All records shall document the specific service provided, the number of services or items comprising the service provided, the extent of the service provided, the dates on which the service is provided, and the individual providing the service. Patient account and financial records shall also include documentation of charges, identify other payment resources pursued, indicate the date and amount of all debit or credit billing actions, and support the appropriateness of the amount billed and paid. For cost reimbursed services, the provider shall maintain adequate records to thoroughly explain how the amounts reported on the cost statement were determined. The records shall be accurate and in sufficient detail to substantiate the data reported;

(b) Clinical records, including records of all therapeutic services, shall document the client's diagnosis and the medical need for the service. The client's record shall be annotated each time a service is provided and signed or initialed by the individual who provided the service or shall clearly indicate the individual who provided the service. For purposes of medical review, the Authority adopts Medicare’s electronic signature policy as outlined in the CMS Medicare Program Integrity Manual. Information contained in the record shall be appropriate in quality and quantity to meet the professional standards applicable to the provider or practitioner and any additional standards for documentation found in this rule, the individual provider rules, and any relevant contracts. When a provider maintains records electronically, within an EHR, EMR or other electronic clinical trial management or billing system, the provider must be able to provide:

(A) hard copy versions, upon request; and

(B) an auditable means of demonstrating the date the record was created, the identity of the creator of a record, the date the record was modified, what was modified in the record, and the identity and credentials of any individual who has modified the record.

(C) If the provider maintains records electronically or permits the use of electronic signatures, the provider must document any aspect of the provision of services. The provider must maintain appropriate safeguards to assure the authenticity of the electronic records and signatures.

(c) Electronic Data Transmissions shall comply with the Uniform Electronic Transactions Act cited in ORS chapter 84 and OAR 943-120-0100;

(d) Policies and procedures shall ensure the maintenance of the confidentiality of medical record information. These procedures ensure the provider may release information in accordance with federal and state statutes, ORS 179.505 through 179.507, 411.320, and 433.045, 42 CFR part 2, 42 CFR subpart F, 45 CFR 205.50.

(e) Retain clinical records for seven years and financial and other records described in paragraphs (a) and (b) of this rule for at least five years from the date(s) of service.

(f) Record requirements applicable only to providers who are providing routine services for clinical trials:

(A) Information must be retained and provided if requested for medical review, audit or investigation by Authority, DOJ MFCU or other state or federal regulators and shall include:

(i) The trial name, sponsor, and sponsor-assigned protocol number (This is the number assigned by the National Library of Medicine (NLM) ClinicalTrials.gov).

(ii) A copy of the member’s signed consent form

(B) Record for clinical trials must be maintained and accessible for 10 years

(3) Upon written request from the Authority, the Medicaid Fraud Control Unit Oregon Secretary of State, the Department of Health and Human Services (DHHS), or their authorized representatives furnish requested documentation immediately or within the time-frame specified in the request. Copies of the documents may be furnished unless the originals are requested. At their discretion, official representatives of the Authority, Medicaid Control Unit, or DHHS may review and copy the original documentation in the provider's place of business. Upon the written request of the provider, the program or the unit may, at their sole discretion, modify or extend the time for providing records if, in the opinion of the program or unit good cause for an extension is shown. Factors used in determining whether good cause exists include:

(a) Whether the written request was made in advance of the deadline for production;

(b) If the written request is made after the deadline for production, the amount of time elapsed since that deadline;

(d) The reason(s) for not meeting the deadline;

(e) The degree of control that the provider had over its ability to produce the records prior to the deadline;

(f) Other extenuating factors.

(4) Access to records, inclusive of medical charts and financial records does not require authorization or release from the client if the purpose is:

(a) To perform billing review activities;

(b) To perform utilization review activities;

(d) To facilitate payment authorization and related services;

(e) To investigate a client's contested case hearing request;

(f) To facilitate investigation by the Medicaid Fraud Control Unit or DHHS; or

(g) Where review of records is necessary to the operation of the program.

(5) Failure to comply with requests for documents within the specified time-frames means that the records subject to the request may be deemed by the Authority not to exist for purposes of verifying appropriateness of payment, medical appropriateness, the quality of care, and the access to care in an audit or overpayment determination may subject the provider to possible denial or recovery of payments made by the Division or to sanctions.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065, 414.115, 414.125, 414.135 & 414.145
DMAP 84-2023, amend filed 11/30/2023, effective 12/01/2023
DMAP 40-2015, f. & cert. ef. 7-1-15
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 19-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 31-1999, f. & cert. ef. 10-1-99
OMAP 10-1999, f. & cert. ef. 4-1-99
OMAP 20-1998, f. & cert. ef. 7-1-98
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0040
HR 41-1991, f. & cert. ef. 10-1-91
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0180
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81, Renumbered from 461-013-0060
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1380 Compliance with Federal and State Statutes

(1) When a Provider submits a claim for medical services or supplies provided to a Division of Medical Assistance Programs (Division) client, Division shall deem the submission as a representation by the medical Provider to the Medical Assistance Program of the medical Provider's compliance with the applicable sections of the federal and state statutes referenced in this rule:

(a) 45 CFR Part 84 which implements Title V, Section 504 of the Rehabilitation Act of 1973;

(b) 42 CFR Part 493 Laboratory Requirements and ORS 438 (Clinical Laboratories).

(c) Unless exempt under 45CFR Part 87 for Faith-Based Organizations (Federal Register, July 16, 2004, Volume 69, #136), or other federal provisions, the Provider must comply and, as indicated, cause all sub-contractors to comply with the following federal requirements to the extent that they are applicable to the goods and services governed by these rules. For purposes of these rules, all references to federal and state laws are references to federal and state laws as they may be amended from time to time:

(A) The Provider must comply and cause all subcontractors to comply with all federal laws, regulations, executive orders applicable to the goods and services provided under these rules. Without limiting the generality of the foregoing, the Provider expressly agrees to comply and cause all subcontractors to comply with the following laws, regulations and executive orders to the extent they are applicable to the goods and services provided under these rules:

(i) Title VI and VII of the Civil Rights Act of 1964, as amended;

(ii) Sections 503 and 504 of the Rehabilitation Act of 1973, as amended;

(iii) The Americans with Disabilities Act of 1990, as amended;

(iv) Executive Order 11246, as amended;

(v) The Health Insurance Portability and Accountability Act of 1996;

(vi) The Age Discrimination in Employment Act of 1967, as amended, and the Age Discrimination Act of 1975, as amended;

(vii) The Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, (viii) all regulations and administrative rules established pursuant to the foregoing laws;

(viii) All other applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations;

(ix) All federal law governing operation of Community Mental Health Programs, including without limitation, all federal laws requiring reporting of client abuse. These laws, regulations and executive orders are incorporated by reference herein to the extent that they are applicable to the goods and services governed by these rules and required by law to be so incorporated. No federal funds may be used to provide services in violation of 42 USC 14402.

(B) Any Provider that receives or makes annual payments under the Title XIX State Plan of at least $5,000,000, as a condition of receiving such payments, shall:

(i) Establish written policies for all employees of the entity (including management), and of any contractor, subcontractor, or agent of the entity, that provide detailed information about the False Claims Act established under sections 3729 through 3733 of title 31, United States Code, administrative remedies for false claims and statements established under chapter 38 of title 31, United States Code, any Oregon State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblowing protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs (as defined in section 1128B(f));

(ii) Include as part of written policies, detailed provisions regarding the entity’s policies and procedures for detecting and preventing fraud, waste and abuse; and

(iii) Include in any employee handbook for the entity, a specific discussion of the laws described in (i), the rights of the employees to be protected as whistleblowers, and the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse.

(C) If the goods and services governed under these rules exceed $10,000, the Provider must comply and cause all subcontractors to comply with Executive Order 11246, entitled “Equal Employment Opportunity,” as amended by Executive Order 11375, and as supplemented in Department of Labor regulations (41 CFR Part 60);

(D) If the goods and services governed under these rules exceed $100,000, the Provider must comply and cause all subcontractors to comply with all applicable standards, orders, or requirements issued under Section 306 of the Clean Air Act (42 U.S.C. 7606), the Federal Water Pollution Control Act as amended (commonly known as the Clean Water Act—33 U.S.C. 1251 to 1387), specifically including, but not limited to, Section 508 (33 U.S.C. 1368). Executive Order 11738, and Environmental Protection Agency regulations (40 CFR Part 32), which prohibit the use under non-exempt Federal contracts, grants or loans of facilities included on the EPA List of Violating Facilities. Violations must be reported to the Authority, the federal Department of Health and Human Services (DHHS) and the appropriate Regional Office of the Environmental Protection Agency. The Provider must include and cause all subcontractors to include in all contracts with subcontractors receiving more than $100,000, language requiring the subcontractor to comply with the federal laws identified in this section;

(E) The Provider must comply and cause all subcontractors to comply with applicable mandatory standards and policies relating to energy efficiency that are contained in the Oregon energy conservation plan issued in compliance with the Energy Policy and Conservation Act, 42 U.S.C. 6201 et seq. (Pub. L. 94-163);

(F) The Provider certifies, to the best of the Provider’s knowledge and belief, that:

(i) No federal appropriated funds have been paid or shall be paid, by or on behalf of the Provider, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any federal contract, grant, loan or cooperative agreement;

(ii) If any funds other than federal appropriated funds have been paid or shall be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal contract, grant, loan or cooperative agreement, the Provider must complete and submit Standard Form LLL, “Disclosure Form to Report Lobbying” in accordance with its instructions;

(iii) The Provider must require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients and subcontractors must certify and disclose accordingly;

(iv) This certification is a material representation of fact upon which reliance was placed when this Provider agreement was made or entered into. Submission of this certification is a prerequisite for making or entering into this Provider agreement imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the required certification will be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

(G) If the goods and services funded in whole or in part with financial assistance provided under these rules are covered by the Health Insurance Portability and Accountability Act or the federal regulations implementing the Act (collectively referred to as HIPAA), the Provider agrees to deliver the goods and services in compliance with HIPAA. Without limiting the generality of the foregoing, goods and services funded in whole or in part with financial assistance provided under these rules are covered by HIPAA. The Provider must comply and cause all subcontractors to comply with the following:

(i) Individually Identifiable Health Information about specific individuals is confidential. Individually Identifiable Health Information relating to specific individuals may be exchanged between the Provider and the Authority for purposes directly related to the provision to clients of services that are funded in whole or in part under these rules. However, the Provider must not use or disclose any Individually Identifiable Health Information about specific individuals in a manner that would violate Authority Privacy Rules, or Authority Notice of Privacy Practices, if done by the Authority. A copy of the most recent Authority Notice of Privacy Practices is posted on the Authority Web site or may be obtained from the Authority;

(ii) If the Provider intends to engage in Electronic Data Interchange (EDI) transactions with the Authority in connection with claims or encounter data, eligibility or enrollment information, authorizations or other electronic transactions, the Provider must execute an EDI Trading Partner Agreement with the Authority and must comply with the Authority EDI rules;

(iii) If a Provider reasonably believes that the Provider’s or the Authority’s data transactions system or other application of HIPAA privacy or security compliance policy may result in a violation of HIPAA requirements, the Provider must promptly consult the Authority Privacy Officer. The Provider or Authority may initiate a request to test HIPAA transactions, subject to available resources and the Authority testing schedule.

(H) The Provider must comply and cause all subcontractors to comply with all mandatory standards and policies that relate to resource conservation and recovery pursuant to the Resource Conservation and Recovery Act (codified at 42 USC 6901 et. seq.). Section 6002 of that Act (codified at 42 USC 6962) requires that preference be given in procurement programs to the purchase of specific products containing recycled materials identified in guidelines developed by the Environmental Protection Agency. Current guidelines are set forth in 40 CFR Parts 247;

(I) The Provider must comply and, if applicable, cause a subcontractor to comply, with the applicable audit requirements and responsibilities set forth in the Office of Management and Budget Circular A-133 entitled “Audits of States, Local Governments and Non-Profit Organizations;”

(J) The Provider must not permit any person or entity to be a subcontractor if the person or entity is listed on the non-procurement portion of the General Service Administration’s “List of Parties Excluded from Federal Procurement or Nonprocurement Programs” in accordance with Executive Orders No. 12,549 and No. 12,689, “Debarment and Suspension”. (See 45 CFR part 76). This list contains the names of parties debarred, suspended, or otherwise excluded by agencies, and Providers and subcontractors declared ineligible under statutory authority other than Executive Order No. 12549. Subcontractors with awards that exceed the simplified acquisition threshold must provide the required certification regarding their exclusion status and that of their principals prior to award;

(K) The Provider must comply and cause all subcontractors to comply with the following provisions to maintain a drug-free workplace:

(i) The Provider certifies that it shall provide a drug-free workplace by publishing a statement notifying its employees that the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance, except as may be present in lawfully prescribed or over-the-counter medications, is prohibited in the Provider's workplace or while providing services to Authority clients. The Provider's notice must specify the actions that shall be taken by the Provider against its employees for violation of such prohibitions;

(ii) Establish a drug-free awareness program to inform its employees about the dangers of drug abuse in the workplace, the Provider's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations;

(iii) Provide each employee to be engaged in the performance of services under these rules a copy of the statement mentioned in paragraph (J)(i) above in this section;

(iv) Notify each employee in the statement required by paragraph (J)(i) of this section that, as a condition of employment to provide services under these rules, the employee shall abide by the terms of the statement and notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction;

(v) Notify the Authority within ten (10) days after receiving notice under subparagraph (J)(iv) of this section from an employee or otherwise receiving actual notice of such conviction;

(vi) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program by any employee who is so convicted as required by Section 5154 of the Drug-Free Workplace Act of 1988;

(vii) Make a good-faith effort to continue a drug-free workplace through implementation of subparagraphs (J)(i) through (J)(vi) of this section;

(viii) Require any subcontractor to comply with subparagraphs (J)(i) through (J)(vii) of this section;

(ix) Neither the Provider, nor any of the Provider's employees, officers, agents or subcontractors may provide any service required under these rules while under the influence of drugs. For purposes of this provision, "under the influence" means observed abnormal behavior or impairments in mental or physical performance leading a reasonable person to believe the Provider or Provider's employee, officer, agent or subcontractor has used a controlled substance, prescription or non-prescription medication that impairs the Provider or Provider's employee, officer, agent or subcontractor's performance of essential job function or creates a direct threat to Authority clients or others. Examples of abnormal behavior include, but are not limited to hallucinations, paranoia or violent outbursts. Examples of impairments in physical or mental performance include, but are not limited to slurred speech, difficulty walking or performing job activities;

(x) Violation of any provision of this subsection may result in termination of the Provider agreement under these rules.

(L) The Provider must comply and cause all sub-contractors to comply with the Pro-Children Act of 1994 (codified at 20 USC section 6081 et. seq.);

(M) The Provider must comply with all applicable federal and state laws and regulations pertaining to the provision of Medicaid Services under the Medicaid Act, Title XIX, 42 USC Section 1396 et. Seq., and CHIP benefits established by Title XXI of the Social Security Act, including without limitation:

(i) Keep such records as are necessary to fully disclose the extent of the services provided to individuals receiving Medicaid assistance and must furnish such information to any state or federal agency responsible for administering the Medicaid program regarding any payments claimed by such person or institution for providing Medicaid Services as the state or federal agency may from time to time request. 42 USC Section 1396a(a)(27); 42 CFR 431.107(b)(1) & (2); 42 CFR 457.950(a)(3);

(ii) Comply with all disclosure requirements of 42 CFR 1002.3(a) and 42 CFR 455 Subpart (B); 42 CFR 457.950(a)(3);

(iii) Maintain written notices and procedures respecting advance directives in compliance with 42 USC Section 1396a(a)(57) and (w), 42 CFR 431.107(b)(4), and 42 CFR 489 subpart I;

(iv) Certify when submitting any claim for the provision of Medicaid Services that the information submitted is true, accurate and complete. The Provider must acknowledge Provider’s understanding that payment of the claim shall be from federal and state funds and that any falsification or concealment of a material fact may be prosecuted under federal and state laws.

(2) Hospitals, Nursing Facilities, Home Health Agencies (including those providing personal care), Hospices and Health Maintenance Organizations shall comply with the Patient Self-Determination Act as set forth in Section 4751 of OBRA 1991. To comply with the obligation under the above listed laws to deliver information on the rights of the individual under Oregon law to make health care decisions, the named Providers and organizations shall give capable individuals over the age of 18 a copy of "Your Right to Make Health Care Decisions in Oregon," copyright 1993, by the Oregon State Bar Health Law Section. Out-of-State Providers of these services should comply with Medicare, Medicaid and CHIP regulations in their state. Submittal to the Division of the appropriate billing form requesting payment for medical services provided to a Medicaid/CHIP eligible client shall be deemed representation to the Division of the medical Provider's compliance with the above-listed laws.

(3) Providers described in ORS chapter 419B are required to report suspected child abuse to their local Authority Children, Adults and Families office or police, in the manner described in ORS 419.

(4) The Clinical Laboratory Improvement Act (CLIA), requires all entities that perform even one laboratory test, including waived tests on, "materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings" to meet certain federal requirements. If an entity performs tests for these purposes, it is considered, under CLIA to be a laboratory.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024
DMAP 28-2023, minor correction filed 04/27/2023, effective 04/27/2023
DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10
OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 10-1999, f. & cert. ef 4-1-99
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0040 & 410-120-0400
HR 41-1991, f. & cert. ef. 10-1-91
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0160 & 461-013-0180
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82, Renumbered from 461-013-0060
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1385 Compliance with Public Meetings Law

(1) Advisory committees with the authority to make decisions for, conduct policy research for, or make recommendations on administration or policy related to the medical assistance programs operated by the Authority pursuant to ORS Chapter 414 must comply with provisions of ORS 192.610 to 192.690 — Public Meetings Law.

(2) This rule applies to those advisory committees of the medical assistance programs operated under ORS Chapter 414 that are both:

(a) Created by state constitution, statutes, administrative rule, order, intergovernmental agreement, or other official act, including direct or delegated authority from the Director of the Authority; and

(b) Comprised of at least two committee members who are not employed by a public body.

(3) Advisory committees subject to this rule must comply with the following provisions:

(a) Meetings shall be open to public attendance unless an executive session is authorized. Committees shall meet in a place accessible to persons with disabilities and, upon request, shall make a good faith effort to provide a sign language interpreter for persons with hearing impairment;

(b) Groups shall provide advanced notice of meetings, location, and principal subjects to be discussed. Posting notices on the Web site operated by the Authority or Health System Division (Division) shall be sufficient compliance of the advanced notice requirement.

(c) Groups shall take minutes at meetings and make them available to the public upon request to the contact person identified on the public notice;

(d) Any meeting that is held through the use of telephone or other electronic communication must be conducted in accordance with the Public Meetings Law.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.227
DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023
DMAP 29-2023, minor correction filed 04/27/2023, effective 04/27/2023
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 62-2001, f. 12-28-01, cert. ef. 1-1-02

Or. Admin. R. 410-120-1390 Premium Sponsorships

(1) Premium donations made for the benefit of one or more specified the Division of Medical Assistance Programs (Division) clients will be referred to as a Premium Sponsorship and the donor shall be referred to as a sponsor.

(2) The Authority may accept Premium Sponsorships consistent with the requirements of this rule. The Authority may adopt such forms and reporting requirements, and change the forms and reporting requirements, as necessary to carry out its functions under this rule. The Authority may identify one or more designees to perform one or more of the functions of Authority under this rule.

(3) This rule does not create or establish any Premium Sponsorship program. The Authority does not operate or administer a Premium Sponsorship program. The Authority does not find sponsors for clients or take requests or applications from clients to be sponsored.

(4) This rule does not create a right for any Division client to be sponsored. Premium Sponsorship is based solely on the decisions of sponsors. The Authority only applies the Premium Sponsorship funds that are accepted by the Authority as instructed by the sponsor. The Authority does not determine who may be sponsored. Any operations of a Premium Sponsorship program are solely the responsibility of the sponsoring entity.

(5) A Premium Sponsorship amount that is not actually received by the Division client will not be deemed to be cash or other resource attributed to the Division client, except to the extent otherwise required by federal law. A Division client’s own payment of his or her obligation, or payment made by an authorized representative of the Division client, is not a sponsorship except to the extent that the authorized representative is otherwise subject to subsection (8) of this rule.

(6) Nothing in this rule alters the Division client’s personal responsibility for assuring that his or her own payments (including current or past due premium payments) are made on time as required under any Authority rule

(7) If the Authority accepts a Premium Sponsorship payment for the benefit of a specified client, the Authority or its designee will credit the amount of the sponsorship payment toward any outstanding amount owed by the specified client. The Authority or its designee is not responsible for notifying the client that a Premium Sponsorship payment is made or that a sponsorship payment has stopped being made.

(8) If a sponsor is a health care Provider, or an entity related to a health care Provider, or an organization making a donation on behalf of such Provider or entity, the following requirements apply:

(a) The Authority will decline to accept Premium Sponsorships that are not “bona fide donations” within the meaning of 42 CFR 433.54. A Premium Sponsorship is a “bona fide donation” if the sponsorship has no direct or indirect relationship to Medicaid payments made to a health care Provider, a related entity providing health care items or services, or other Providers furnishing the same class of items or services as the Provider or entity;

(b) For purposes of this rule, terms “health care Provider,” “entity related to a health care Provider” and “Provider-related donation” will have the same meaning as those terms are defined in 42 CFR 433.52. A health care Provider includes but is not limited to any Provider enrolled with Division or contracting with a Prepaid Health Plan for services to Oregon Health Plan clients.

(c) Premium Sponsorships made to the Authority by a health care Provider or an entity related to a health care Provider do not qualify as a “bona fide donation” within the meaning of subsection (a) of this section, and the Authority will decline to accept such sponsorships;

(d) If a health care Provider or an entity related to a health care Provider donates money to an organization, which in turn donates money in the form of a Premium Sponsorship to the Authority, the organization will be referred to as an organizational sponsor. The Authority may accept Premium Sponsorship from an organizational sponsor if the organizational sponsor has completed the initial Authority certification process and complies with this rule. An organizational sponsor may not itself be a health care Provider, Provider-related entity, or a unit of local government;

(e) All organizational sponsors that make Premium Sponsorships to the Authority may be required to complete at least annual certifications, but no more frequently than quarterly. Reports submitted to the Authority will include information about the percentage of its revenues that are from donations by Providers and Provider-related entities. The organization’s chief executive officer or chief financial officer must certify the report. In its certification, the organizational sponsor must agree that its records may be reviewed to confirm the accuracy, completeness and full disclosure of the donations, donation amounts and sources of donations. The Authority will decline to accept donations or gifts from an organization that refuses or fails to execute necessary certifications or to provide access to documentation upon request;

(f) The Authority will decline to accept Premium Sponsorships from an organizational sponsor if the organization receives more than 25 percent of its revenue from donations from Providers or Provider-related entities during the State’s fiscal year;

(g) Any health care Provider or entity related to a health care Provider making a donation to an organizational sponsor, or causing another to make a Premium Sponsorship on its behalf, and any organizational sponsor, is solely responsible for compliance with laws and regulations applicable to any donation, including but not limited to 42 CFR 1001.951 and 1001.952.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 72-2004, f. 9-23-04, cert. ef. 10-1-04
OMAP 38-2004(Temp), f. 5-28-04 cert. ef. 6-1-04 thru 11-15-04

Or. Admin. R. 410-120-1395 Program Integrity

(1) The Oregon Health Authority (Authority) uses several approaches to promote program integrity. These rules describe program integrity actions related to provider payments. Our program integrity goal is to pay the correct amount to a properly enrolled provider for covered, medically appropriate services provided to an eligible client according to the client's benefit package of health care services in effect on the date of service. Types of program integrity activities include but are not limited to the following activities:

(a) Medical review and prior authorization processes, including all actions taken to determine the medical appropriateness of services or items;

(b) Provider obligations to submit correct claims;

(d) Implementation of Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards to improve accuracy and timeliness of claims processing and encounter reporting;

(e) Provider credentialing activities;

(f) Accessing federal Department of Health and Human Services database (exclusions);

(g) Quality improvement activities;

(h) Cost report settlement processes;

(i) Audits;

(j) Investigation of fraud or prohibited kickback relationships;

(k) Coordination with the Department of Justice Medicaid Fraud Control Unit (MFCU) and other health oversight authorities.

(2) Providers must maintain clinical, financial and other records, capable of being audited or reviewed, consistent with the requirements of OAR 410-120-1360, Requirements for Financial, Clinical and Other Records, in the General Rules Program, the Oregon Health Plan administrative rules, and the rules applicable to the service or item.

(3) The following people may review a request for services or items, or audit a claim for care, services or items, before or after payment, for assurance that the specific care, item or service was provided in accordance with the Division of Medical Assistance Program's (Division) rules and the generally accepted standards of a provider's field of practice or specialty:

(a) Authority, Department staff or designee; or

(b) Medical utilization and review contractor; or

(d) Federal or state oversight authority.

(4) Payment may be denied or subject to recovery if the review or audit determines the care, service or item was not provided in accordance with Division rules or does not meet the criteria for quality or medical appropriateness of the care, service or item or payment. Related provider and Hospital billings will also be denied or subject to recovery.

(5) When the Authority determines that an overpayment has been made to a provider, the amount of overpayment is subject to recovery.

(6) The Authority may communicate with and coordinate any program integrity actions with the MFCU, DHHS, and other federal and state oversight authorities.

(7) The Authority must notify HHS-OIG within 20 working days of any disclosures from the date it receives the information, or takes any adverse action to limit the ability of an individual or entity to participate in its program as provided in 42 CFR 1002.3(b). This includes, but is not limited to, suspension, denials, terminations, settlement agreements and situations where an individual or entity voluntarily with draws from the program to avoid a formal sanction.

(8) When the Authority initiates an exclusion under § 1002.210, it must notify the individual or entity subject to the exclusion and other state agencies, the state medical licensing board, the public, beneficiaries, and others as provided in § 1001.2005 and § 1001.2006.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05

Or. Admin. R. 410-120-1396 Provider and Contractor Audits

(1) Individual providers or business entities (providers) enrolled with or under contract with the Oregon Department of Human Services (ODHS) or the Oregon Health Authority (Authority) (hereafter referred to as “provider”) receiving payments from the ODHS or Authority are subject to audit or other post payment review procedures (hereafter referred to as “audit”) for all payments applicable to items or services furnished or supplied by the provider to or on behalf of ODHS or Authority Medicaid members.

(a) Audit rules and procedures ensure proper payments were made based on requirements applicable to covered services, ensure program integrity of the Authority or ODHS programs and services as outlined in Oregon Administrative Rules (OARs) 407-120-0310, 943-120-1505, 410-120-1160, OAR Ch 410 sections applicable to specific services, and establish authority for the Authority Office of Program Integrity (OPI) to recover overpayments and discover possible instances of fraud, waste, and abuse in the Medicaid member program.

(b) Audits are conducted of providers paid under Oregon’s Medicaid program who direct, furnish or supply items or services as fee-for-service providers, as defined in OAR 410-120-0000, or as participating providers, non-participating providers or subcontractors of a Managed Care Entity (MCE), as defined in OAR 410-141-3500. This includes all provider types enrolled by the Authority or ODHS under OAR 410-120-1260 or by agreement or contract with the Authority or ODHS.

(c) The Authority and ODHS share duties and functions related to audits and have the authority to determine which of the two agencies is authorized to fulfill a particular function.

(2) The Authority may employ internal staff, consultants, or contractors, or cooperate with federal or state oversight authorities or other designees to conduct an audit or perform other audit procedures. The Authority will assign a contractor or one or more individuals to conduct the audit (hereafter referred to as “auditor”).

(a) The Authority shall ensure auditors have appropriate training and subject matter expertise to conduct the audit and perform other audit procedures.

(b) OPI may, at its sole discretion, modify or extend the timeframes noted in this rule when the provisions of OAR 410-120-0011 are in effect or in response to local emergencies that are outside the control of Authority or providers.

(3) The auditor and OPI management will determine the scope, time period, objective, and subject matter covered by the audit.

(4) The authority for access to records is found in OARs 407-120-0370 and 410-120-1360, as well as other terms of agreements or contracts authorizing access to records for audit purposes.

(5) The auditor may conduct an on-site audit, examine and copy records using provider’s on-site resources or at the provider’s expense, interview employees, and conduct such work as the auditor determines is necessary to provide sufficient and competent evidential basis for drawing conclusions about the audit subject matter.

(6) The auditor may conduct a desk audit of records requested by the auditor and supplied by the provider, at the provider’s expense, or other source as necessary for the auditor to determine sufficient and competent evidential basis for drawing conclusions about the audit subject matter.

(7) The auditor may consider other audits of the provider including, but not limited to, reviews conducted by a federal or state authority, which may include those performed by internal auditors, audit organizations, or contractors established by the federal or state government for the auditing of the Authority or DHS programs, an MCE, and the provider's independent audit of the provider's claims and financial statements.

(a) The auditor may consider other indicators or issues related to program integrity activities. The auditor may also consider past or present Authority program integrity activities conducted under OAR 410-120-1395 and OAR 407-120-0310 that have identified same or similar instances of non-compliance.

(b) The auditor shall determine the scope of other audit work and evaluate the reliability of its relationship to the scope and objective of the audit being conducted in determining the weight to be given to the other audit work.

(c) The auditor may, in addition to the record request sent to the provider, request documentation from an MCE when the items or services within the audit scope were furnished or supplied to or on behalf of a Medicaid member enrolled in that MCE.

(A) The auditor shall provide copies of the preliminary and final audit report to the MCE;

(B) The MCE must hold the audit, the preliminary report and its preliminary findings in confidence and must not act directly or indirectly to discourage a provider’s participation in the audit;

(C) The auditor may consider the MCE documentation requested by the auditor as necessary for the auditor to determine sufficient and competent evidential basis for drawing conclusions about the audit subject matter; and

(D) The auditor shall evaluate the relevance and reliability of the MCE’s documents in relationship to the scope and objective of the audit being conducted in determining the weight to be given to any MCE documents.

(8) The Authority’s OPI may use a statistical sampling methodology in audits. The OPI may use, but is not limited to, the statistical and sampling methods in the book entitled " Sampling Techniques, 3rd Edition," written by William G. Cochran, (Cochran) For sampling and calculation of overpayments.

(a) In determining whether to use an overpayment calculation method in section (8) of this rule, the auditor and OPI management may consider:

(A) The provider's overall error rate identified in the audit;

(B) If past audits have identified the same or similar instances of non-compliance;

(D) Any adverse impact on the health of members and their access to services in the provider's service area.

(b) If OPI determines an overpayment amount by a random sampling and overpayment calculation method in section (8) of this rule, the provider may request, for the services within the scope of the audit, a 100 percent audit of all billings from the same time period of the audit submitted to the DHS or Authority for items or services furnished or supplied to or on behalf of members. If a 100 percent audit is requested by the provider:

(A) Payment and arrangement for a 100 percent audit must be paid by the provider requesting the audit;

(B) The audit must be conducted by an independent auditor or other individual whose qualifications the Authority has determined, in writing, to be acceptable; who is knowledgeable with OAR and the billing and coding standards covering the payments in question; and who must waive any privilege to OPI in relation to the work papers and work product of the independent auditor;

(C) The 100 percent audit must be completed within 90 calendar days of the provider's request to use such audit in lieu of the Authority’s sample, or within a timeframe approved by OPI;

(D) The provider must waive all rights to appeal the findings of the independent auditor; and

(E) The independent auditor must produce a final audit report or similar document, detailing the findings of the 100 percent audit, including the overpayment assessment and recommendations to the provider and OPI. The independent auditor’s work papers must be made available, at the providers’ expense, to OPI upon request.

(c) For providers furnishing or supplying items or services to or on behalf of Medicaid members enrolled in an MCE, the overpayment amount will be determined by OPI:

(A) Using the Authority fee-for-service fee schedule in effect on the date of service; or

(B) If requested by the MCE, OPI may use the MCE’s rate per claim or encounter when that rate increases the accuracy of the calculated overpayment. OPI reserves the right to review the MCE rate for reasonability.

(9) The auditor shall prepare a records request letter and deliver the records request to the provider in person, or by secure encrypted email, or registered or certified mail.

(a) A provider’s refusal to accept the secure encrypted email, registered or certified mail or in-person delivery will not stop the audit from proceeding.

(b) The provider shall have 30 calendar days from the postmark date or email sent date of the records request letter to respond with the requested records. The provider must provide immediate access to the requested records when the request is made in person.

(c) The provider may request, in writing to the auditor, up to a 15 calendar-day extension to the records request due date for preparing documentation. The request must be received by OPI before the timeframe in subsection 9(b) of this rule expires and the extension must be authorized in writing by the auditor or OPI management. An additional 15 calendar-day extension, requested in writing, may be granted at the discretion of OPI management.

(10) The auditor will prepare a preliminary audit report or similar document. The preliminary audit report informs the provider of the opportunity to provide additional documentation to the auditor about the services within the scope of the preliminary audit report:

(a) Auditor will deliver the preliminary audit report to the provider in person, by secure encrypted email, or by registered or certified mail;

(b) Refusing to accept the secure encrypted email, registered or certified mail or in-person delivery will not stop the audit process from proceeding;

(c) The provider and MCE have 30 calendar days from the in-person delivery date, postmark date, or email sent date of the preliminary audit report to respond to the audit. The MCE must hold the preliminary report and its preliminary findings in confidence and must not act directly or indirectly to discourage a provider’s participation in the audit;

(d) The provider may request, in writing to the auditor, up to a 15 calendar-day extension to the preliminary audit report response due date for submitting additional documentation. The request must be received before the 30 calendar-day timeframe in subsection 10(c) of this rule expires and the extension must be authorized in writing by the auditor or OPI management. An additional 15 calendar-day extension, requested in writing, may be granted at the discretion of OPI management.

(11) The auditor will prepare a final audit report or similar document which is also the Authority’s final order. The final audit report includes an overpayment amount, findings, recommendations, and appeal rights. Auditor will deliver the final audit report to the provider in person, by secure encrypted email or by registered or certified mail. When the audit is of an MCE provider, the auditor will also deliver a copy of the final audit report to the MCE in person, by secure encrypted email or by registered or certified mail:

(a) The overpayment amount stated in the final audit report includes but is not limited to the amount of overpayment OPI is authorized to recover and:

(A) Is not limited to amounts determined by criminal or civil proceedings;

(B) May include interest to be charged at allowable state rates; and

(b) Refusing to accept the secure encrypted email, registered or certified mail or in-person delivery will not stop the audit process from proceeding;

(c) If the provider or MCE disagrees with the final audit report or the overpayment amount, the provider or MCE may appeal the decision. The provider or MCE must appeal the decision within 30 calendar days from the in-person delivery date, postmark date, or email sent date of the final audit report by submitting a written request for either an administrative review or a contested case hearing to OPI. The written request for appeal must outline in detail the areas of disagreement:

(A) The OPI Administrator or designee is referred to as “Administrator” in this rule. The Administrator will determine which appeals may be suitable for review as administrative review or a contested case hearing, taking into consideration the issues presented in the request for appeal and the purposes served by administrative review in section (13) or contested case hearing in section (14) of this rule;

(B) If the Administrator decides the determinations of the final audit report or the content of appeal is appropriate for a contested case hearing or denies a request for an administrative review on the basis the appeal should be heard as a contested case hearing, the Administrator notifies the provider and refers the appeal directly to the Office of Administrative Hearings (OAH) for a contested case hearing pursuant to these rules;

(C) The MCE is a party in an appeal only where a provider furnished or supplied items or services to the MCE member. An MCE appeal of the final audit report or the overpayment amount will proceed as outlined in sections (11) through (21) of this rule;

(D) The MCE must comply with provisions for handling of overpayments made to providers as required by any contracts or agreements between the MCE and the Authority.

(12) If a provider or MCE fails to request an appeal within 30 calendar days from the date of the final audit report, the overpayment amount, findings, and all recommendations shall become final. Provider or MCE appeal requests submitted to OPI must:

(a) Be in writing to the Administrator:

(A) The appeal request is not required to follow a specific format as long as it provides clear written expression from the provider or MCE expressing disagreement with the final audit report findings;

(B) The request must specify issues or decisions being appealed and the specific reason for the appeal on each finding or decision. The request must provide specifics for each claim such as procedure code, diagnosis code, reason for denial, administrative rules, or other authority applicable to the issue, and why the provider or MCE disagrees with the decision. If this information is not included in the appeal request in a manner that reasonably permits the Administrator to understand the decision being appealed or the basis for the appeal, the request will be returned to the provider or MCE and the provider or MCE must resubmit the appeal within 10 calendar days from the date on OPI’s notice returning the appeal.

(b) Be received by OPI within 30 calendar days from the in-person delivery date, postmark date, or email sent date of the final audit report:

(A) Late appeal requests require written supporting documentation clearly explaining the reason for a provider’s or MCE’s late request. The Administrator will determine whether failure to file a timely request was caused by circumstances beyond the provider’s or MCE’s control and enter an order accordingly. The Administrator may conduct further inquiry as deemed appropriate. In determining timelines of filing a request for review, the amount of time the Administrator determines accounts for circumstances beyond the control of the provider is not counted.

(B) The untimely request may be referred to the OAH for a hearing on the question of timeliness.

(13) Administrative review allows an opportunity for the Administrator to review a decision affecting the provider or MCE. Administrative review is limited to legal or policy issues where there is a stipulation of factual matters to be heard. The administrative review may be conducted as a desk review of available documentation or as a meeting, in-person or through the use of telephonic or electronic communication, between OPI and the provider or MCE, at the sole discretion of Administrator:

(a) Administrative review meetings will be:

(A) Scheduled within 90 calendar days from receipt of the written request by the Administrator:

(i) The Administrator will send written notice to the provider or MCE of the date, time, and place of the meeting;

(ii) If the Administrator decides a preliminary meeting, in-person or through the use of telephonic or electronic communication, between the provider or MCE and OPI may assist the administrative review, the Administrator shall provide written notice to the provider or MCE of the date, time, and place the preliminary meeting is scheduled.

(B) Held in Salem, unless otherwise stipulated to by OPI;

(D) Authority or ODHS staff will not be available for cross-examination;

(E) Authority or ODHS staff may attend and participate in the meeting; and

(F) The provider or MCE is not required to be represented by legal counsel and will be given ample opportunity to present relevant information from the existing case record.

(b) If a provider, MCE, or legal representative fails to appear at the administrative review meeting, the final audit report, all findings including the overpayment, and recommendations and sanctions as specified in the report will become final. In addition, the provider or MCE may not further appeal the final audit report. The Administrator may cancel the final order upon request of the provider, MCE, or legal representative. The provider or MCE must be able to show evidence that the provider, MCE, or legal representative was unable to attend the Administrative Review and unable to request a postponement for reasons beyond the provider’s or MCE’s control;

(c) The results of the meeting shall be sent to the provider or MCE, in writing, by secure encrypted email, registered or certified mail within 30 calendar days of the conclusion of the administrative review proceedings. The result of the administrative review is final;

(d) All administrative review decisions are subject to procedures established in OARs 137-004-0080 to 137-004-0092 and judicial review under ORS 183.484 in the Circuit Court.

(14) The contested case hearing process is conducted in accordance with ORS 183.411 to 183.497 and the Attorney General’s Uniform and Model Rules of Procedure for the Office of Administrative Hearings (OAH), OAR 137-003-0501 to 137-003-0700:

(a) If the Administrator decides an informal pre-hearing conference, in-person or through the use of telephonic or electronic communication, between the provider or MCE and OPI shallassist the contested case hearing, the Administrator will notify the provider or MCE of the time and place of the informal pre-hearing conference without the presence of an Administrative Law Judge (ALJ). The purpose of the informal pre-hearing conference is to:

(A) Provide an opportunity to settle the matter or discuss Model Rules of Procedure for contested case hearings listed in OAR 137-003-0575. Any agreement reached in a pre-hearing conference will be submitted to the ALJ in writing or presented orally on the record at the contested case hearing;

(B) Provide an opportunity for the provider or MCE and OPI to review the information, correct any misunderstanding of facts, and understand the reason for the action that is the subject of the contested case hearing; or

(b) Prior to the date of the contested case hearing, the provider may request additional informal conferences with OPI representatives. The request must be made in writing to the Administrator. A second informal conference may be granted at the sole discretion of the Administrator if the second informal conference is determined to facilitate the contested case hearing process or resolution of disputed issues;

(d) The OAH shall serve a proposed order on behalf of OPI unless the Administrator notifies the parties that OPI will issue the final order. The proposed order shall become the final order if no exceptions are filed within the time specified in this rule;

(e) The provider or MCE may file exceptions or written argument to the proposed order to be considered by OPI. The exceptions must be in writing and received by OPI within 10 calendar days after the date the proposed order is issued. No additional evidence may be submitted. After receiving the exceptions or argument, OPI may adopt the proposed order as the final order, amend the order, or prepare a new order;

(f) A provider or MCE may withdraw a contested case hearing request at any time. The OAH will send a final order confirming the withdrawal to the provider pursuant to OARs 137-003-0670 to 137-003-0672.

(15) If the provider, MCE, or legal representative fail to appear at the contested case hearing, OPI may elect one of the following options at its sole discretion:

(a) The contested case hearing request may be dismissed by order. The Administrator may cancel the dismissal order upon request of the provider, MCE, or legal representative. The provider or MCE must be able to show evidence that the provider, MCE, or legal representative was unable to attend the hearing and unable to request a postponement for reasons beyond the provider’s or MCE’s control;

(b) OPI may enter a final order by default when the Administrator determines that the issuance of a final order with findings is appropriate as a basis of sanction authority or to establish a basis for future sanction authority or other reason consistent with the administration of the Authority or DHS programs. The designated record, for purposes of a default order, will be the record as designated in the notice issued to the provider or MCE. If not so designated, the designated record will consist of the files and records held by OPI in the contested case hearing packet prepared by OPI.

(16) Final orders are effective immediately upon being signed or as otherwise specified in the order.

(a) Final orders resulting from a provider’s or MCE’s withdrawal of a contested case hearing request is effective the date the provider’s or MCE’s request is received by OPI or the OAH, whichever is sooner.

(b) When the provider, MCE, or legal representative fails to appear for the contested case hearing, the effective date of the dismissal order or the final order by default is the date of the scheduled contested case hearing.

(17) The burden of presenting evidence to support a fact or position in an administrative review or a contested case hearing rests on the provider and MCE. All copies of documentation and records submitted by a provider or MCE for an appeal are provided at the provider’s or MCE’s expense.

(18) The Administrator, in consultation with the Authority or DHS Director, may grant the provider or MCE the relief sought at any time.

(19) For providers furnishing or supplying items or services to or on behalf of Medicaid members enrolled in an MCE, overpayments shall be paid by the MCE within 30 calendar days from the postmark date or email sent date of the final audit report:

(a) The MCE may submit a request to OPI for a modified payment plan as provided in section (20) of this rule to satisfy this requirement;

(b) The Authority shall recoup from future MCE payments up to the amount of the overpayment and any applicable interest. The auditor and OPI management may not waive this overpayment requirement;

(c) MCE recovery of overpayments made by the MCE to the applicable provider must comply with any MCE contractual requirements. MCEs’ internal overpayment recovery practices are not covered by this rule.

(20) Overpayments shall be paid within 30 calendar days from the postmark date or email sent date of the final audit report. The provider or MCE may submit a request to OPI for a payment plan to satisfy this requirement. The auditor and OPI management may not waive this overpayment requirement:

(a) A request for an administrative review or contested case hearing will not change the date the overpayment is due, or a payment plan is to commence, unless otherwise stipulated in writing by the Administrator. OPI will make any change in the reimbursement period or terms in writing:

(A) The request for a payment plan or to modify an existing payment plan must be made in writing to OPI. The auditor or OPI management will notify the provider or MCE, in writing, of the decision regarding acceptance or denial of the request;

(B) If the payment plan is agreeable, the auditor will ensure the payment plan is in writing and signed by all parties. A payment plan may include charging interest at the allowable state rate pursuant to ORS 82.010.

(b) If the provider or MCE refuses to reimburse the overpayment or does not adhere to an agreed upon payment schedule, OPI may take one or more of the following actions:

(A) Recoup future payments up to the amount of the overpayment and any applicable interest;

(B) Pursue civil action to recover the overpayment and any applicable interest;

(D) Recoup the overpayment through other methods pursuant to the provider’s or MCE’s contract or agreement with the Authority or DHS; or

(E) Recommend suspension or termination of the provider’s enrollment in Authority or DHS medical programs and the Authority assigned provider number in the Oregon Medicaid Program. This action may be reported by the Authority to CMS, or other federal or state entities as appropriate.

(c) As a result of a contested case hearing or an administrative review, the amount of the overpayment may be reduced in part or in full;

(d) OPI may at any time decrease the amount of the overpayment in accordance with this rule. The provider or MCE will be notified of any changes in writing by secure encrypted email, certified or registered mail. OPI will refund the provider or MCE any monies paid to OPI in excess of the overpayment;

(e) If a provider is terminated from participation in Authority or DHS programs or sanctioned for any reason, OPI may pursue civil action to recover any amounts due and payable, to include any applicable interest;

(f) The provider or MCE may be liable for up to triple the total overpayment amount of the current final audit report when:

(A) The auditor, in the course of an audit, discovers the provider employs the same or similar improper billing practices as previously identified in a preceding final audit report published by the OPI;

(B) The provider has previously been warned in writing by the Authority, DHS, Centers for Medicare and Medicaid (CMS) or their designee, or the Department of Justice (DOJ) of the same or similar improper billing practices.

(21) Providers and MCEs who conduct electronic data transactions with the Authority or DHS must adhere to requirements of OARs 943-120-0100 to 943-120-0200 and OARs 407-120-0100 to 407-120-0200. If the provider maintains financial or clinical records electronically, the provider must ensure the use of electronic record keeping systems does not alter the requirements of OARs 410-120-1360 and OAR 407-120-0370:

(a) When the provider maintains financial or clinical records electronically, the provider must be able to provide OPI with hard copy versions, upon request. The provider must also be able to provide an auditable means of demonstrating the date the record was created, the identity of the creator of a record, the date the record was modified, what was modified in the record, and the identity and credentials of any individual who has modified the record. The provider must supply the information to individuals authorized to review the provider's records pursuant to OAR 410-120-1360 and OAR 407-120-0370.

(b) If the provider maintains records electronically or permits the use of electronic signatures, the provider must document any aspect of the provision of services. The provider must maintain appropriate safeguards to assure the authenticity of the electronic records and signatures.

(A) The provider is not allowed to challenge the authenticity or admissibility of the electronic signature in any audit, review, hearing, or other legal proceeding.

(B) The provider is not allowed to challenge the authenticity or admissibility of the electronic documents and records due to internal transaction or operation failures of a provider’s or its billing entity's electronic record system in any audit, review, hearing or other legal proceeding.

(c) Providers must comply with the documentation review requirements in OAR 410-120-1360 and OAR 407-120-0370 by providing the electronic record in a secure Health Insurance Portability and Accountability Act (HIPAA) compliant electronic format acceptable to an authorized reviewer. Provider’s electronic records must be made available within the audit timeframes in this rule and at the providers’ expense. The authorized reviewer must agree to receive the documentation electronically.

History

Statutory/Other Authority: ORS 413.032
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023
DMAP 63-2020, adopt filed 12/17/2020, effective 01/01/2021

Or. Admin. R. 410-120-1397 Recovery of Overpayments to Providers — Recoupments and Refunds

(1) The Authority requires Providers to submit true, accurate, and complete claims or encounters. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certification by the Provider of the following: “This is to certify that the foregoing information is true, accurate, and complete. I understand that payment of this claim or encounter will be from federal and state funds, and that any falsification or concealment of a material fact maybe prosecuted under federal and state laws.”

(2) Authority staff or a designee may review or audit a claim before or after payment for assurance that the specific care, item or service was provided in accordance with the Authority rules and policies, the terms applicable to the agreement or contract and the generally accepted standards of a Provider's field of practice or specialty:

(a) “Designee” for the purposes of these rules includes, but is not limited to, a medical, behavioral, drug or dental utilization and review or a post-payment review contractor;

(b) “Claim” for the purposes of these rules includes requests for payment under a Provider enrollment agreement or contract, whether submitted as a claim or invoice or other method for requesting payment authorized by administrative rule, and may include encounter data.

(3) The Authority may deny payment or may deem payments subject to recovery as an Overpayment if a review or audit determines the care, item, drug or service was not provided in accordance with Authority policy and rules applicable agreement, intergovernmental agreement or contract, including but not limited to the reasons identified in section (5) of this rule. Related Provider and Hospital billings will also be denied or subject to recovery.

(4) If a Provider determines that a submitted claim or encounter is incorrect, the Provider is obligated to submit an Individual Adjustment Request and refund the amount of the Overpayment, if any, consistent with the requirements of OAR 410-120-1280. When the Provider determines that an Overpayment has been made, the Provider must notify and reimburse the Authority immediately, following one of the reimbursement procedures described below:

(a) Submitting a Medicaid adjustment form (OHA 1036-Individual Adjustment Request) will result in an offset of future payments. It is not necessary to refund with a check if an offset of future payments is adequate to repay the amount of the Overpayment; or

(b) Providers preferring to make a refund by check must attach a copy of the remittance statement page indicating the Overpayment information, except as provided by subsection (c) of this section. If the Overpayment involves an insurance payment or another Third Party Resource, Providers will attach a copy of the remittance statement from the insurance payer:

(A) Refund checks not involving Third Party Resource payments will be made payable to Division Receipting — Checks in Salem;

(B) Refunds involving Third Party Resource payments will be made payable and submitted to the Division Receipting — MPR Checks in Salem;

(c) Providers making a refund by check based on audit or post-payment review will follow the reimbursement procedures described in the Overpayment notice or order in the audit or on post-payment review, if specified.

(5) The Authority may determine, as a result of review or other information, that a payment should be denied or that an Overpayment has been made to a Provider, which indicates that a Provider may have submitted claims or encounters, or received payment to which the Provider is not properly entitled. Such payment denial or Overpayment determinations may be based on, but not limited to, the following grounds:

(a) The Authority paid the Provider an amount in excess of the amount authorized under the State Plan or Authority rule, agreement or contract;

(b) A third party paid the Provider for services (or a portion thereof) previously paid by the Authority;

(d) The Authority paid for claims submitted by a data processing agent for whom a written Provider or Billing Agent/Billing Service agreement or other applicable contract or agreement was not on file at the time of submission;

(e) The Authority paid for care, items, drugs or services and later determined they were not part of the client's benefit package;

(f) Coding, processing submission or data entry errors;

(g) The care, items, drugs or service was not provided in accordance with Authority rules or does not meet the criteria for quality of care, item, drug or service, or medical appropriateness of the care, item, drug, service or payment;

(h) The Authority paid the Provider for care, items, drugs or services, when the Provider did not comply with Authority rules and requirements for reimbursement.

(6) Prior to identifying an Overpayment, the Authority or designee may contact the Provider for the purpose of providing preliminary information and requesting additional documentation. Provider must provide the requested documentation within the time frames requested.

(7) When an Overpayment is identified, The Authority will notify the Provider in writing, as to the nature of the discrepancy, the method of computing the dollar amount of the Overpayment, and any further action that the Authority may take in the matter:

(a) The Authority notice may require the Provider to submit applicable documentation for review prior to requesting an appeal from the Authority, and may impose reasonable time limits for when such documentation must be provided in order to be considered by the Authority.

(b) The Provider may appeal a Authority notice of Overpayment in the manner provided in OAR 410-120-1560.

(8) The Authority may recover Overpayments made to a Provider by direct reimbursement, offset, civil action, or other actions authorized by law:

(a) The Provider must make a direct reimbursement to the Authority within thirty (30) calendar days from the date of the notice of the Overpayment, unless other regulations apply;

(b) The Authority may grant the Provider an additional period of time to reimburse the Authority upon written request made within thirty (30) calendar days from the date of the notice of Overpayment if the Provider provides a statement of facts and reasons sufficient to show that repayment of the Overpayment amount should be delayed pending appeal because:

(A) The Provider will suffer irreparable injury if the Overpayment repayment is not delayed;

(B) There is a plausible reason to believe that the overpayment is not correct or is less than the amount in the notice, and the Provider has timely filed an appeal of the Overpayment, or that Provider accepts the amount of the Overpayment but is requesting to make repayment over a period of time;

(C) A proposed method for assuring that the amount of the Overpayment can be repaid when due with interest, including but not limited to a bond, irrevocable letter of credit or other undertaking, or a repayment plan for making payments including interest over a period of time.

(D) Granting the delay will not result in substantial public harm;

(E) Affidavits containing evidence relied upon in support of the request for stay:

(F) The Authority may consider all information in the record of the Overpayment determination, including Provider cooperation with timely provision of documentation, in addition to the information supplied in Provider’s request. If Provider requests a repayment plan, the Authority may require conditions acceptable to the Authority before agreeing to a repayment plan. The Authority must issue an order granting or denying a repayment delay request within thirty (30) calendar days after receiving it.

(c) Except as otherwise provided in subsection (b) a request for a hearing or administrative review does not change the date the repayment of the Overpayment is due, and if the outcome of the appeal reduces the amount of the Overpayment, that amount previously paid by the Provider in response to the notice of Overpayment will be refunded to the Provider;

(d) The Authority may withhold payment on pending claims and on subsequently received claims for the amount of the overpayment when Overpayments are not paid as a result of section (7)(a) of this rule;

(e) The Authority may file a civil action in the appropriate Court and exercise all other civil remedies available to the Authority in order to recover the amount of an overpayment.

(9) In addition to any overpayment, the Authority may impose a Sanction on the Provider in connection with the actions that resulted in the overpayment. the Authority may, at its discretion, combine a notice of Sanction with a notice of Overpayment.

(10) Voluntary submission of an Individual Adjustment Request or overpayment amount after notice from the Authority does not prevent the Authority from issuing a notice of Sanction, but the Authority may take such voluntary payment into account in determining the Sanction.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 413.351, 414.805 & 416.350
DMAP 30-2023, minor correction filed 04/28/2023, effective 04/28/2023
DMAP 24-2007, f. 12-11-07 cert. ef. 1-1-08
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05

Or. Admin. R. 410-120-1400 Provider Sanctions

(1) The Authority recognizes two classes of Medicaid provider sanctions, mandatory and discretionary, outlined in sections (4) and (5) of this rule.

(2) The Authority shall impose sanctions on Medicaid providers at the discretion of the Authority Director or delegate. Nothing in this rule limits the ability of Authority or the Oregon Department of Human Services (ODHS) to also seek monetary recovery, or pursue remedies specific to a contract with Authority or ODHS, or as otherwise permitted by state or federal law. Authority sanctions of its contracted managed care entities are governed by OAR 410-141-3530.

(3) Authority may sanction and suspend or terminate a provider who:

(a) is applying for enrollment, re-enrollment or revalidation as an Oregon Medicaid provider;

(b) is enrolled as an Oregon Medicaid provider; regardless of whether enrollment is continuous or active; or

(c) was an enrolled Oregon Medicaid provider at the time the sanctionable conduct, action, conditions or activity occurred.

(4) The Authority shall impose mandatory sanctions and deny enrollment, suspend or terminate the enrollment of the provider from participation in Oregon’s medical assistance programs, regardless of whether the provider was directly enrolled or contracted by Authority or was enrolled or contracted by an Authority designee including but not limited to ODHS:

(a) When a provider, or any person with five (5) percent or more direct or indirect ownership interest in the provider, or any agent, affiliate or managing employee of the provider is, or was in the preceding then (10) years, convicted (as that term is defined in 42 CFR 1001.2) of a felony or misdemeanor related to a crime, or violation of Title XVIII, XIX, or XX of the Social Security Act, any other federal program, or related state laws; regardless of whether an appeal from that judgment is pending;

(b) When a provider, or any person with five (5) percent or more direct or indirect ownership interest in the provider, or any agent, affiliate or managing employee of the provider, is excluded from participation in federal or state health care programs by the Office of the Inspector General of the U.S. Department of Health and Human Services (OIG) or from Medicare (Title XVIII) program of the Social Security Act as determined by the Secretary of Health and Human Services; regardless of whether an appeal from that judgment is pending. The provider shall also be terminated or suspended from participation with the Authority for the duration of exclusion or suspension from the Medicare program or by the OIG;

(c) When a provider fails to disclose ownership or controlling information required under 42 CFR 455.104 that is required to be reported at the time the provider submits a provider enrollment application, or when there is a material change in the information that must be reported or information related to business transactions required to be provided under 42 CFR 455.105 upon request of federal or state authorities.

(d) When a provider, or any person with a five (5) percent or greater direct or indirect ownership or controlling interest in the provider, fails to submit sets of fingerprints in a form and manner determined by the Authority within 30 days of CMS or an Authority request;

(e) When a provider, or any person with a five (5) percent or greater direct or indirect ownership or control interest, an agent, affiliate or managing employee of the provider, fails to submit timely and accurate information, comply with Authority screening methods, or both as required under 42 CFR 455 Subpart E;

(f) When a provider fails to permit access to a provider location for any site visit under 42 CFR §455.432; unless the Authority determines the termination is not in the best interest of the Medicaid program. 42 CFR 455.416(f);

(g) When a provider is suspended or excluded from participation in a state Medicaid or CHIP program for reasons related to professional competence, professional performance, debarment or other reason;

(h) If the Authority:

(A) Determines that the provider has falsified any information provided on the application for enrollment; or

(B) Cannot verify the identity of the provider.

(i) When a provider is convicted of fraud related to any federal, state, or locally financed health care program or commits fraud, receives kickbacks, or commits other acts that are subject to criminal or civil penalties under the Medicare or Medicaid statutes;

(j) When a provider is convicted of interfering with the investigation of health care fraud;

(k) When a provider is convicted of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance;

(l) When a provider, or any person with five (5) percent or more direct or indirect ownership interest in the provider, or any agent, affiliate or managing employee of the provider, is subject to an adverse Legal Action including conviction of a felony crime against persons, financial crime(s) or misdemeanor conviction of patient abuse or neglect, theft, embezzlement or fraud;

(m) When there is a credible allegation of fraud as defined in 42 CFR 455.2 for which an investigation is pending under the Medicaid program, unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23;

(n) When Authority receives a referral from a Medicaid Fraud Control Unit (MFCU), Authority will initiate any available administrative or judicial action to recover improper payments to a provider and suspend the provider to prevent future payments, unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23;

(o) When the provider’s enrollment has been terminated or revoked for cause by Medicare or another state’s Medicaid program and such termination has been published in the Data Exchange System (DEX), the Authority will terminate the provider’s enrollment in its program pursuant to 42 CFR 455.416(c) and455.101.

(5) The Authority may impose discretionary sanctions and deny enrollment, suspend or terminate a provider when the Authority determines that the provider fails to meet one or more of the Authority’s requirements in all applicable administrative rules or the contract between Authority and the provider governing participation in its medical assistance programs. Conditions that may result in a discretionary sanction include but are not limited to:

(a) breech of the provider agreement;

(b) actions of any state licensing authority for reasons relating to the provider's professional competence, professional conduct, quality of care, or financial integrity including but not limited to:

(A) Having the health care license suspended or revoked, or otherwise loses their license; or

(B) Surrendering their license while a formal disciplinary proceeding is pending before the licensing authority.

(c) Suspended or excluded from participation in any federal or state health care program for reasons related to professional competence, professional performance, or other reason;

(d) Billing excessive charges (i.e., charges more than the usual charge). Furnishes items or services substantially more than the Authority client’s needs or more than those services ordered by a medical provider or more than generally accepted standards or of a quality that fails to meet professionally recognized standards;

(e) Fails to furnish medically necessary services as required by law or contract with the Authority if the failure has adversely affected (or has a substantial likelihood of adversely affecting) the Authority client;

(f) Fails to disclose required ownership information;

(g) Fails to supply requested records and information on subcontractors, providers, and suppliers of goods or services;

(h) Fails to supply requested payment information;

(i) Fails to provide or disclose requested information or documentation to Authority, within the timeframe listed on the Authority’s written request;

(j) Fails to grant access or to furnish as requested, records, or grant access to facilities upon request of the Authority or designee, ODHS, the Authority’s Office of Program Integrity (OPI), OIG, or the State of Oregon's Department of Justice (DOJ) Medicaid Fraud Control Unit (MFCU) conducting their regulatory or statutory functions;

(k) In the case of a hospital, fails to take corrective action as required by the Authority, based on information supplied by the Quality Improvement Organization to prevent or correct inappropriate admissions or practice patterns, within the time specified by the Authority;

(L) Defaults on repayment of federal or state government scholarship obligations or loans in connection with the provider's health profession education. The Authority:

(A) Shall make a reasonable effort to secure payment;

(B) Shall take into account access of beneficiaries to services; and

(m) Submits one or more claims with required data missing or incorrect;

(n) Fails to comply with the requirements of OAR 410-120-1280, Ch 410, Ch 943, Ch 309 or any other OAR CH applicable to the service or good when billing or submitting claims or encounters to Authority.

(o) Fails to develop, maintain, and retain in accordance with OAR 410-120-1360 and relevant rules Ch 410, Ch 943, Ch 309 or any other OAR CH applicable to the service or good and standards adequate clinical or other records that document the medical appropriateness, nature, and extent of the health care provided;

(p) Fails to develop, maintain, and retain in accordance with OAR 410-120-1360 and relevant rules in Ch 410, Ch 943, Ch 309 or any other OAR CH applicable to the provider and adequate financial records as defined in OAR 410-120-0000 that document charges incurred by a client and payments received from any source;

(q) Fails to develop, maintain, and retain adequate financial or other records of all assets, liabilities, income, and expenses that support information submitted on a cost report;

(r) Fails to follow generally accepted accounting principles or accounting standards or cost principles sanctioned by recognized authoritative bodies such as the Governmental Accounting Standard Board and the Financial Accounting Standards Board and required by federal or state laws, rules, or regulations applicable to Medicaid;

(s) Submits claims or written orders contrary to generally accepted standards of medical practice of the provider receiving or requesting payment;

(t) Submits claims or encounters for services that exceed that requested or agreed to by the member or the responsible relative or guardian or requested by another medical provider;

(u) Breaches the terms of the provider contract or the provider enrollment agreement with the Authority or Oregon Department of Human Services (ODHS). This includes failure to comply with the terms of the provider certifications on the medical claim form;

(v) Rebates or accepts a fee or portion of a fee or charge for an Authority client referral, or collects a portion of a service fee from the client and bills the Authority for the same service;

(w) Fails to disclose information requested on the provider enrollment application or as otherwise requested by Authority;

(x) Fails to correct deficiencies in operations after receiving written notice of the deficiencies from the Authority; including deficiencies in licensing or certification procedures;

(y) Submits any claim or encounter for payment for which payment has already been made by the Authority or any other source unless the amount of the payment from the other source is clearly identified;

(z) Threatens, intimidates, or harasses members or their relatives in an attempt to influence payment rates or affect the outcome of disputes between the provider and the Authority;

(aa) Fails to properly account for an Authority member's Personal Incidental Funds, including but not limited to using a client's Personal Incidental Funds for payment of services that are included in a medical facility's all-inclusive rates;

(bb) Provides or bills for services provided by ineligible or unsupervised or unqualified employees, providers, or interns;

(cc) Participates in collusion that results in an inappropriate money flow between the parties involved, for example, referring clients unnecessarily to another provider;

(dd) Refuses or fails to repay in accordance with an accepted schedule an overpayment established by the Authority, Authority’s OPI, MFCU or as ordered by a court;

(ee) Refuses or fails to repay in accordance with an accepted schedule repayment of identified overpayment or settlement agreements established by Authority, Authority OPI, MFCU or as ordered by a court;

(ff) Fails to report to Authority or ODHS payments received from any other source after the Authority made payment for the service;

(gg) Fails to comply with federal or state statutes and regulations or policies of the Authority or ODHS that are applicable to the provider;

(hh) Fails to obtain or maintain required provider credentials or has credentials suspended or otherwise revoked by the credentialing entity, for any reason;

(ii) Fails to correct subcontractor deficiencies in operations or non-compliance with Medicaid program requirements after receiving written notice of the deficiencies from the Authority;

(jj) Acts to discriminate among members on the basis of their health status or need for health care services, or on the basis of race, color, national origin, religion, sex, sexual orientation, marital status, age, or disability; violates member civil rights under Title VI of the Civil Rights Act and ORS Chapter 659A;

(kk) When a person with five (5) percent or more direct or indirect ownership interest in the provider, or an agent, affiliate, supplier or managing employee of the provider is found to be in violation, independently or in tandem with the provider, of one or more of the provision of section (4) or (5) of this rule;

(LL) When a MCE participating provider or subcontractor enrolled or seeking enrollment as an encounter only provider is found to be in violation of one or more of the provision of section (4) or (5) of this rule;

(mm) Submits a bill or invoice or otherwise seeks payment from a member for any services covered by Medicaid fee-for-service or through contracted health care plans, except as authorized by OAR 410-120-1280. If the member was eligible for medical assistance on the date of service, and the provider does not have a completed signed agreement to pay form (3165, 3166), the provider is not allowed to bill the member, collect payment from the member, or assign an unpaid claim to a collection agency or similar entity pursuant to ORS 414.066, except as authorized by section (5) of OAR 410-120-1280. The Authority sanction of the provider may include but is not limited to any amount necessary to fully repay the member for the billed services, fines, fees or other financial penalties imposed on the member by the provider or any third party collections agency, and any accrued interest.

(nn) Failure to comply with Authority or its designee’s notice that the provider is in violation of ORS 414.066 within 30 days or within the time required in the Authority’s written notice;

(oo) Failure to comply with federal or state statutes and regulations or policies of the Authority that are applicable to the provider;

(pp) No claims have been submitted in an 18-month period. The provider must reapply for enrollment;

(6) A provider excluded, suspended, or terminated from participation in a federal or state medical program, such as Medicare or Medicaid or CHIP, or whose license or certification to practice is suspended or revoked by a state licensing board or Authority may not submit encounters or claims to the Authority for payment, either personally or through claims submitted by any billing agent/service, billing provider, or other provider for any services or supplies provided under the medical assistance programs, except those services or supplies provided prior to the date of exclusion, suspension, or termination; unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23.

(7) A Provider may not submit encounters or claims for payment to the Authority for payment for any services or supplies provided by an individual provider or provider entity that is excluded, suspended, or terminated from participation in a federal or state medical program or whose license to practice is suspended or revoked by a state licensing board, except for those services or supplies provided prior to the date of exclusion, suspension, or termination; unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23.

(8) When any one of the provisions of sections (4) or (5) of this rule are violated, the Authority may suspend or terminate the billing provider’s enrollment agreement or the enrollment agreement of any individual provider who is in violation. When a provider is sanctioned, all other enrolled providers in which the sanctioned provider has ownership or controlling interest of five (5) percent or greater, may also be sanctioned and suspended or terminated.

(9) When any of the provisions of section (4) are violated, Authority shall withhold and recover all payments made to the provider for services furnished after the effective date of the sanction; unless good cause not to recover payments exists, in accordance with 42 CFR §455.23. When provisions of section (5) are violated, Authority may withhold and recover all payments made to the provider for services furnished after the effective date of the sanction.

(10) When a provider sanctioned as a result of exclusion from participation in federal or another state’s health care programs the scope of the provider appeal of the Authority’s Action is limited to a review of whether the provider was, in fact, terminated by the initiating program. The appeal will not review the underlying reasons for the initiating termination. The provider must contact the federal or state agency which issued the initial decision.

(11) Authority shall, for any provider or any person with a relationship with the provider who meets the circumstances for exclusion listed in 42 CFR 1001.1001, promptly notify the OIG of any action(s) Authority takes on the provider’s application for enrollment in the program and any action(s) taken to limit the ability of a provider, whether an individual or entity, to participate in Oregon’s Medicaid program, regardless of what such an action is called. This includes, but is not limited to, suspension actions, settlement agreements and situations where the provider voluntarily withdraws from the program to avoid formal sanction(s).

(12) Authority shall, for any provider sanctioned by the Authority under this rule 410-120-1400 list the name(s) of the provider, NPI, duration and the effective date of the sanction on the Authority’s website.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.025 & 414.065
DMAP 84-2023, amend filed 11/30/2023, effective 12/01/2023
DMAP 31-2023, minor correction filed 04/28/2023, effective 04/28/2023
DMAP 78-2018, amend filed 06/27/2018, effective 07/01/2018
DMAP 61-2013, f. 10-31-13, cert. ef. 11-1-13
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0600
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0095
AFS 42-1983, f. 9-2-83, ef. 10-1-83
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 47-1982, f. 4-30-82, ef. 5-1-82

Or. Admin. R. 410-120-1460 Type and Conditions of Sanction

(1) The Health Systems Division (Division) may impose mandatory Sanctions on a Provider pursuant to OAR 410-120-1400(4), in which case:

(a) The Provider shall be either Terminated or Suspended from participation in Oregon's medical assistance programs;

(b) If Suspended, the minimum duration of Suspension shall be determined by the Secretary of the Department of Health and Human Services (DHHS), under the provisions of 42 CFR Parts 420, 455, 1001, or 1002. The Authority may Suspend a Provider from participation in Oregon's medical assistance programs longer than the minimum Suspension determined by the DHHS Secretary.

(2) The Division may impose the following discretionary Sanctions on a Provider pursuant to OAR 410-120-1400(5):

(a) The Provider may be Terminated from participation in Oregon's medical assistance programs;

(b) The Provider may be Suspended from participation in Oregon's medical assistance programs for a specified length of time, or until specified conditions for reinstatement are met and approved by Division;

(d) The Provider may be required to attend Provider education sessions at the expense of the Sanctioned Provider;

(e) The Division may require that payment for certain services are made only after the Division has reviewed documentation supporting the services;

(f) The Division may recover investigative and legal costs;

(g) The Division may provide for reduction of any amount otherwise due the Provider.The reduction may be up to three times the amount a Provider sought to collect from a client in violation of OAR 410-120-1280; or

(h) Any other Sanctions reasonably designed to remedy or compel future compliance with federal, state, or Division regulations.

(3) The Division shall consider the following factors in determining the Sanction(s) to be imposed:

(a) Seriousness of the offense(s);

(b) Extent of violations by the Provider;

(d) Prior imposition of Sanctions;

(e) Prior Provider education;

(f) Provider willingness to comply with program rules;

(g) Actions taken or recommended by licensing boards or a Quality Improvement Organization (QIO);

(h) Adverse impact on the health of Division clients living in the Provider's service area; and

(i) Any other relevant factors.

(4) Immediate Suspension. When a Provider fails to meet one or more of the requirements identified in this rule the Division, at its sole discretion, may immediately Suspend the Povider’s Authority assigned billing number to prevent public harm or inappropriate expenditure of public funds:

(a) The Provider subject to immediate Suspension is entitled to a contested case hearing as outlined in OAR 410-120-1600 through 410-120-1700 to determine whether the Provider's authority assigned number shall be revoked;

(b) The notice requirements described in section (5) of this rule do not stop the Division’s decision of immediate Suspension to prevent public harm or inappropriate expenditure of public funds. Suspension shall start immediately while the notice and contested case hearing rights are exercised.

(5) If the Authority decides to Sanction a Provider, the Division shall notify the Provider of the intent to Sanction by certified mail, personal delivery service or other traceable services such as email with delivery and read receipt. Notices sent certified mail shall be sent to the “mail-to” address on file for the Provider at the time of Sanction. Notices sent via secure email shall be sent to the Providers email if on file or the most current contact on file for the Provider a time of Sanction. The notice of immediate or proposed Sanction shall identify:

(a) The factual basis used to determine the alleged deficiencies;

(b) Explanation of actions expected of the Provider;

(d) The Provider's right to dispute the Division's allegations, and submit evidence to support the Provider's position; and

(e) The Provider's right to appeal Division's proposed actions pursuant to OARs 410-120-1560 through 410-120-1700.

(6) If the Division makes a final decision to Sanction a Provider, the Division shall notify the Provider in writing at least 15 days before the effective date of action, except in the case of immediate Suspension to avoid public harm or inappropriate expenditure of funds.

(7) The Provider may appeal the Division’s immediate or proposed Sanction(s) or other action(s) the Authority intends to take, including but not limited to the following list. The Provider must appeal these actions separately from any appeal of audit findings and overpayments:

(a) Termination or Suspension from participation in the Medicaid-funded medical assistance programs;

(b) Termination or Suspension from participation in the Division’s state-funded programs;

(8) Other provisions:

(a) When a Provider has been Sanctioned, all other Provider entities in which the Provider has ownership (five percent or greater) or control of, may also be Sanctioned;

(b) When a Provider has been Sanctioned, the Division may notify the applicable professional society, board of registration or licensure, federal or state agencies, Oregon managed care entities, and the National Practitioner Data Base of the findings and the Sanctions imposed;

(c) At the discretion of the Division, Providers who have previously been Terminated or Suspended may or may not be re-enrolled as Division Providers;

(d) Nothing in this rule prevents the Authority from simultaneously seeking monetary recovery and imposing Sanctions against the Provider;

(e) If the Division discovers continued improper billing practices from a Provider who, after having been previously warned in writing by the Division or the Department of Justice about improper billing practices and has had an opportunity for a contested case hearing, that Provider will be liable to the Division for up to triple the amount of the Division’s established overpayment received as a result of such violation.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0260 & 410-120-0660
HR 41-1991, f. & cert. ef. 10-1-91
HR 19-1990, f. & cert. ef. 7-9-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0095 & 461-013-0140
AFS 33-1986, f. 4-11-86, cert. ef. 6-1-86
AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85
AFS 42-1983, f. 9-2-83, cert. ef. 10-1-83
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82, Renumbered from 461-013-0050
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-120-1510 Fraud and Abuse

(1) This rule sets forth requirements for reporting, detecting and investigating fraud and abuse. The terms fraud and abuse are defined in OAR 410-120-0000. For the purpose of these rules, the following definitions apply:

(a) “Credible allegation of fraud” means an allegation of fraud, that has been verified by the state and has indicia of reliability that comes from any source as defined in 42 CFR 455.2;

(b) “Conviction” or “convicted” means that a judgment of conviction has been entered by a federal, state, or local court regardless of whether an appeal from that judgment is pending;

(c) “Exclusion” means that the Authority or the Department of Human Services (Department) shall not reimburse a specific provider who has defrauded or abused the Authority or Department for items or services which that provider furnished;

(d) “Prohibited kickback relationships” means remuneration or payment practices that may result in federal civil penalties or exclusion for violation of 42 CFR 1001.951;

(e) “Suspension” means the Authority or Department shall not reimburse a specified provider who has been convicted of a program-related offense in a federal, state, or local court for items or services which that provider furnished.

(2) Cases involving one or more of the following situations shall constitute sufficient grounds for a provider fraud referral:

(a) Billing for services, supplies, or equipment that are not provided to or used for Medicaid patients;

(b) Billing for supplies or equipment that are clearly unsuitable for the patient's needs or are so lacking in quality or sufficiency for the purpose as to be virtually worthless;

(d) Materially misrepresenting dates and descriptions of services provided, and the identity of the individual who provided the services or of the recipient of the services;

(e) Duplicate billing of the Medicaid program or of the recipient that appears to be a deliberate attempt to obtain additional reimbursement; and

(f) Arrangements by providers with employees, independent contractors, suppliers, and other various devices such as commissions and fee splitting that appear to be designed primarily to obtain or conceal illegal payments or additional reimbursement from Medicaid.

(3) The provider shall promptly refer all suspected fraud and abuse, including fraud or abuse by its employees or in the Division administration, to the Medicaid Fraud Control Unit (MFCU) of the Department of Justice or to the Department’s Provider Audit Unit (PAU). Contact information may be found online at: http://www.oregon.gov/OHA/HSD/OHP//Pages/Policy-General-Rules.aspx.

(4) If the provider is aware of suspected fraud or abuse by an Authority or Department client, the provider shall report the incident to the Department’s Fraud Investigations Unit (FIU). Contact information may be found online at http://www.oregon.gov/OHA/HSD/OHP//Pages/Policy-General-Rules.aspx.

(5) The provider shall permit the MFCU, Authority, Department, or law enforcement entity, together or separately, to inspect, copy, evaluate, or audit books, records, documents, files, accounts, and facilities without charge, as required to investigate an incident of fraud or abuse. When a provider fails to provide immediate access to records, Medicaid payments may be withheld or suspended.

(6) Providers and their fiscal agents shall disclose ownership and control information and disclose information on a provider's owners and other persons convicted of criminal offenses against Medicare, Medicaid, CHIP, or the Title XX services program. Such disclosure and reporting is made a part of the provider enrollment agreement, and the provider shall update that information with an amended provider enrollment agreement if any of the information materially changes. The Authority or Department shall use that information to meet the requirements of 42 CFR 455.100 to 455.106, and this rule shall be construed in a manner that is consistent with the Authority or Department acting in compliance with those federal requirements.

(7) The Authority or Department may share information for health oversight purposes with the MFCU and other federal or state health oversight authorities.

(8) The Authority or Department may suspend payments in whole or part in a suspected case of fraud or abuse; or where there exists a credible allegation of fraud or abuse presented to the Authority, the Department, or law enforcement entity; or where there is a pending investigation or conclusion of legal proceedings related to the provider's alleged fraud or abuse.

(9) The Authority or Department may take the actions necessary to investigate and respond to credible allegations of fraud and abuse, including but not limited to suspending or terminating the provider from participation in the medical assistance programs, withholding payments or seeking recovery of payments made to the provider, or imposing other sanctions provided under state law or regulations. These actions by the Authority or Department may be reported to CMS, or other federal or state entities as appropriate.

(10) The Authority or Department shall not pay for covered services provided by persons who are currently suspended, debarred, or otherwise excluded from participating in Medicaid, Medicare, CHIP, or who have been convicted of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, XXI, or XX of the Social Security Act or related laws.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 34-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 40-2015, f. & cert. ef. 7-1-15
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05

Or. Admin. R. 410-120-1560 Provider Appeals

(1) For purposes of Division provider appeal rules in chapter 410, division 120, the following terms and definitions are used:

(a) “Provider” means an individual or entity enrolled with the Division or under contract with the Division that is subject to the Division rules and that has requested an appeal in relation to health care, items, drugs, or services provided or requested to be provided to a client on a fee-for-service basis or under contract with the Division where that contract expressly incorporates these rules;

(b) “Provider Applicant” means an individual or entity that has submitted an application to become an enrolled provider with the Division, but the application has not been approved;

(c) “Prepaid Health Plan” has the meaning set forth in OAR 410-141-3500, except to the extent that Mental Health Organizations (MHO) have separate procedures applicable to provider grievances and appeals;

(d) “Prepaid Health Plan provider” means an individual or entity enrolled with the Division but that provided health care services, supplies or items to a client enrolled with a PHP, including both participating providers and non-participating providers as those terms are defined in OAR 410-141-0000, except that services provided to a client enrolled with an MHO shall be governed by the provider grievance and appeal procedures administered by the Authority’s Addictions and Mental Health Division;

(e) The “Provider Appeal Rules” refers to the rules in OAR 410-120-1560 to 410-120-1600, describing the availability of appeal procedures and the procedures applicable to each;

(f) “Non-participating provider” has the meaning set forth in OAR 410-141-3500;

(g) Coordinated Care Organization (CCO) has the meaning set forth in OAR 410-141-3500.

(2) A Division enrolled provider may appeal a Division decision in which the provider is directly adversely affected including but not limited to the following:

(a) A denial or limitation of payment allowed for services or items provided;

(b) A denial related to an NCCI edit;

(d) Sanctions imposed, or intended to be imposed, by the Division on a provider or provider entity; and

(e) Division overpayment determinations made under OAR 410-120-1397.

(3) Client appeals of actions must be handled in accordance with OAR 140-120-1860 and 410-120-1865.

(4) A provider appeal is initiated by filing a timely request in writing for review with the Division:

(a) A provider appeal request is not required to follow a specific format as long as it provides a clear written expression from a provider or provider applicant expressing disagreement with a Division decision or from a CCO or PHP provider expressing disagreement with a decision by a CCO or PHP.

(b) The request must identify the decision made by the Division, a CCO, or PHP that is being appealed and the reason the provider disagrees with that decision.

(A) Within 180 calendar days from the date of the Division’s fee-for-service decision;

(B) Within 30 calendar days from the date of the CCO or PHP decision after the provider completes the CCO or PHP appeal process.

(5) Types and methods for provider appeals are:

(a) Claim redeterminations: A Division denial of or limitation of payment allowed, including prior authorization decision, or Division overpayment determination for services or items provided to a client must be appealed as claim re-determinations under OAR 410-120-1570.

(b) Contested Case: A notice of sanctions imposed or intended to be imposed, the effect of the notice of sanction is, or will be, to deny, suspend, or revoke a provider number necessary to participate in the medical assistance on a provider, or provider applicant is entitled to appeal under OAR 410-120-1600. A provider that may appeal a notice of sanction as a contested case may choose to request administrative review instead of contested case hearing if the provider submits a written request for administrative review and agrees in writing to waive the right to a contested case hearing and the Division agrees to review the appeal as an administrative review.

(c) Administrative review: All provider appeals of Division decisions not described in section (5)(a) or (b) of this rule are handled as administrative reviews in accordance with OAR 410-120-1580, unless the Division issues an order granting a contested case hearing.

(6) Decisions that adversely affect a provider may be made by different program areas within the Authority:

(a) Decisions issued by the Office of Payment Accuracy and Recovery (OPAR) or the Authority information security office shall be appealed in accordance with the process described in the notice;

(b) Other program areas within the Authority that have responsibility for administering medical assistance funding, such as nursing home care or community mental health and developmental disabilities program services, may make decisions that adversely affect a provider. Those providers are subject to the provider grievance or appeal processes applicable to those payment or program areas;

(c) Some decisions that adversely affect a provider are issued on behalf of the Division by Authority contractors such as the Division pharmacy benefits manager, by entities performing statutory functions related to the medical assistance programs such as the Drug Use Review Board, or by other entities in the conduct of program integrity activities applicable to the administration of the medical assistance programs. For these decisions made on behalf of the division in which the Division has legal authority to make the final decision in the matter, a provider may appeal the decision to the Division as an administrative review, and the Division may accept the review;

(d) This rule does not apply to contract administration issues that may arise solely between the Division and a CCO or PHP. Those issues shall be governed by the terms of the applicable contract;

(e) The Division provides limited provider appeals for CCO or PHP providers or non-participating providers concerning a decision by a CCO or PHP. In general, the relationship between a CCO or PHP and their providers is a contract matter between them. Client appeals are governed by the client appeal rules, not provider appeal rules.

(A) The CCO or PHP provider seeking a provider appeal must have a current valid provider enrollment agreement with the Division and, unless the provider is a non-participating provider, must also have a contract with the CCO or PHP; and

(B) The CCO or PHP provider or non-participating provider must have exhausted the applicable appeal procedure established by the CCO or PHP, and the request for provider appeal must include a copy of the CCO or PHP written decision that is being appealed and a copy of any CCO or PHP policy being applied in the appeal; and

(C) The CCO or PHP provider appeal or non-participating provider appeal from a CCO or PHP decision is limited to issues related to the scope of coverage and authorization of services under the OHP, including whether services are included as covered on the Prioritized List, guidelines, and in the OHP Benefit package. The Division provider appeal process does not include CCO or PHP payment or claims reimbursement amount issues, except in relation to non-participating provider matters governed by Division rule;

(D) A timely provider request for appeal must be made within 30 calendar days from the date of the CCO or PHP’s decision and include evidence that the PHP was sent a copy of the provider appeal. In every provider appeal involving a CCO or PHP decision, the CCO or PHP shall be treated as a participant in the appeal.

(7) If a provider’s request for appeal is not timely, the Division shall determine whether the failure to file the request was caused by circumstances beyond the control of the provider, provider applicant, or CCO or PHP provider. In determining whether to accept a late request for review, the Division requires the request to be supported by a written statement that explains why the request for review is late. The Division may conduct further inquiry as the Division deems appropriate. In determining timeliness of filing a request for review, the amount of time that the Division determines accounts for circumstances beyond the control of the provider is not counted. The Division may refer an untimely request to the Office of Administrative Hearings for a hearing on the question of timeliness.

(8) The burden of presenting evidence to support a provider appeal is on the provider, provider applicant, CCO, or PHP provider:

(a) Consistent with OAR 410-120-1360, payment on a claim shall be made only for services that are adequately documented and billed in accordance with OAR 410-120-1280 and all applicable administrative rules related to covered services for the client’s benefit package and establishing the conditions under which services, supplies or items are covered, such as the Prioritized List, medical appropriateness and other applicable standards;

(b) Eligibility for enrollment and for continued enrollment is based on compliance with applicable rules, the information submitted or required to be submitted with the application for enrollment and the enrollment agreement, and the documentation required to be produced or maintained in accordance with OAR 410-120-1360.

(9) Provider appeal proceedings, if any, shall be held in Salem, unless otherwise stipulated to by all parties and agreed to by the Division.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
DMAP 32-2023, minor correction filed 04/28/2023, effective 04/28/2023
DMAP 40-2015, f. & cert. ef. 7-1-15
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 13-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 24-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 19-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 41-2000, f. & cert. ef. 12-1-00
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0780
HR 41-1991, f. & cert. ef. 10-1-91
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0191
AFS 51-1985, f. 8-16-85, cert. ef. 9-1-85
AFS 37-1984, f. 8-30-84, cert. ef. 9-1-84
AFS 13-1984(Temp), f. & cert. ef. 4-2-84
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82

Or. Admin. R. 410-120-1570 Claim Re-Determinations

(1) If a provider disagrees with an initial claim determination made by the Division of Medical Assistance Program (Division), the provider may request a review for re-determination of the denied claim payment.

(2) This rule does not apply to determinations that:

(a) Result in a “Notice of Action” that must be provided to the OHP client. If the decision under review requires any notice to the OHP client under applicable rules (OAR 410-120-1860, 410-141-3885), the procedures for notices and hearings must be followed; or

(b) Are made by a CCO or PHP regarding services to a CCO or PHP member. The provider must contact the CCO or PHP in accordance with OAR 410-120-1560.

(3) How to request a redetermination review:

(a) To request a review, the provider must submit a written request to the Division Provider Services Unit within 180 days of the original claim adjudication date;

(b) The written request must include all information needed to adjudicate the claim or support changing the original claim determination, including but not limited to:

(A) A detailed letter of explanation identifying the specific re-determination denial issue and/or alleged error;

(B) All relevant medical records and evidence-based practice data to support the position being asserted on review;

(D) Detailed justification for the re-determination of the denied service; and

(E) A copy of the original claim and a copy of the original denial notice or remittance advice that describes the basis for the claim denial under re-determination;

(F) Any information and/or medical documentation pertinent to support the request and to obtain a resolution of the re-determination review dispute.

(4) A provider requesting a re-determination review must demonstrate one or more of the following reasons that would allow coverage in the particular case:

(a) A below-the-line condition/treatment pair is justified under the co-morbid rule OAR 410-141-3820;

(b) A treatment that is part of a covered complex procedure and/or related to an existing funded condition;

(d) A service that satisfies the Citizenship Waived Medical (CWM) emergency service criteria;

(e) Medical documentation of applicable evidence-based practice literature that is consistent with the condition or service under review;

(f) A service that satisfies the prudent layperson definition of emergency medical condition;

(g) A service intended to prolong survival or palliate symptoms, due to expected length of life consistent with the HSC Statement of Intent for Comfort/Palliative Care;

(h) A service that should be covered where denial was due to technical errors and omissions with the Oregon Health Services Commission’s (HSC) Prioritized List of approved Health Services

(i) Misapplication of a fee schedule;

(j) A denied duplicate claim that the provider believes were incorrectly identified as a duplicate;

(k) Incorrect data items, such as provider number, use of a modifier or date of service, unit changes or incorrect charges;

(l) Errors with the Medicaid Management Information System (MMIS), such as a code is missing in MMIS that the Oregon Health Services Commission (HSC) has placed on the Prioritized List of Health Services;

(m) Services provided without the required prior-authorization, except for those authorizations subject to provision outlined in OAR 410-120-1280(2)(a)(C);

(n) A covered diagnostic service.

(5) The Division will review all re-determination requests as follows:

(a) The review is based on the Division review of supplied documentation and applicable law(s);

(b) The Division may request additional information from the provider that it finds relevant to the request under review;

(c) The Division does not provide a face-to-face or in person meeting with providers as part of the re-determination review process.

(d) The Division will notify a provider requesting review that the re-determination request has been denied if:

(A) The provider did not submit a timely request;

(B) The required information is not provided at the same time the request is submitted; or

(6) The Division’s final decision under this rule is the final decision on appeal. Under ORS 183.484, this decision is an order in other than a contested case. ORS 183.484 and the procedures in OAR 137-004-0080 to 137-004-0092 apply to the Division’s final decision under this rule.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 33-2023, minor correction filed 04/28/2023, effective 04/28/2023
DMAP 82-2022, minor correction filed 10/13/2022, effective 10/13/2022
DMAP 27-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 13-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 24-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 19-2003, f. 3-26-03, cert. ef. 4-1-03

Or. Admin. R. 410-120-1580 Provider Appeals — Administrative Review

(1) An administrative review is a provider appeal process that allows an opportunity for the Administrator of the Division of Medical Assistance Programs (Division) or designee to review a Division decision affecting the provider, provider applicant, Coordinated Care Organization (CCO) or Prepaid Health Plan (PHP) provider, where administrative review is appropriate and consistent with these provider appeal rules OAR 410-120-1560.

(2) Administrative review is an appeal process under OAR 410-120-1560 that addresses primarily legal or policy issues that may arise in the context of a Division decision that adversely affects the Provider and that is not otherwise reviewed as a claim re-determination, a contested case, or client appeal.

(a) If the Division finds that the appeal should be handled as a different form of provider appeal or as a client appeal, the Administrator or designee will notify the provider of this determination.

(b) Within the time limits established by the Division in the administrative review, the provider, provider applicant, CCO or PHP provider must provide Division (and CCO or PHP, if applicable) with a copy of all relevant records, the Division, CCO or PHP decisions, and other materials relevant to the appeal.

(3) If the Administrator or designee decides that a meeting between the provider, provider applicant, CCO or PHP Provider (and CCO or PHP, if applicable) and the Division staff will assist the review, the Administrator or designee will:

(a) Notify the provider requesting the review of the date, time, and place the meeting is scheduled;

(b) Notify the CCO or PHP (when client is enrolled in a CCO or PHP) of the date, time, and place the meeting is scheduled. The CCO or PHP is not required to participate, but is invited to participate in the process.

(4) The review meeting will be conducted in the following manner:

(a) It will be conducted by the Division Administrator, or designee;

(b) No minutes or transcript of the review will be made;

(c) The provider requesting the review does not have to be represented by counsel during an administrative review meeting and will be given ample opportunity to present relevant information;

(d) The Division staff will not be available for cross-examination, but the Division staff may attend and participate in the review meeting;

(e) Failure to appear without good cause constitutes acceptance of the Division’s determination;

(f) The Administrator may combine similar administrative review proceedings, including the meeting, if the Administrator determines that joint proceedings may facilitate the review;

(g) The Division Administrator or designee may request the provider, provider Applicant, CCO or PHP Provider making the appeal to submit, in writing, new information that has been presented orally. In such an instance, a specific date for receiving such information will be established.

(5) The results of the administrative review will be sent to the participants, involved in the review, and to the CCO or PHP when review involved a CCO or PHP provider, in writing, within 30 calendar days of the conclusion of the administrative review proceeding, or such time as may be agreed to by the participants and the Division.

(6) The Division's final decision on administrative review is the final decision on appeal and binding on the parties. Under ORS 183.484, this decision is an order in other than a contested case. ORS 183.484 and the procedures in OAR 137-004-0080 to 137-004-0092 apply to the Division's final decision on administrative review.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 13-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 73-2003, f. & cert. ef. 10-1-03
OMAP 19-2003, f. 3-26-03, cert. ef. 4-1-03
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0800
HR 41-1991, f. & cert. ef. 10-1-91
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0191 & 461-013-0220
AFS 51-1985, f. 8-16-85, cert. ef. 9-1-85
AFS 37-1984, f. 8-30-44, cert. ef. 9-1-84
AFS 13-1984(Temp), f. & cert. ef. 4-2-84
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82

Or. Admin. R. 410-120-1600 Provider Appeals — Contested Case Hearings

(1) A contested case procedure is a hearing that is conducted by the Office of Administrative Hearings where a contested case is appropriate and consistent with the provider appeal rules OAR 410-120-1560. If the request for contested case hearing was timely filed but should have been filed as a claim redetermination or administrative review, or client appeal, Division will refer the request to the proper appeal procedure and notify the Provider, provider applicant, CCO or PHP provider.

(2) Contested case hearings are conducted in accordance with the Attorney General’s model rules at OAR 137-003-0501 to 137-003-0700.

(3) The party to a provider contested case hearing is the provider, provider applicant, CCO or PHP provider who requested the appeal. In the event that Division determines that a CCO or PHP provider is entitled to a Contested Case Hearing under OAR 410-120-1560, the CCO or PHP Provider and the CCO or PHP are parties to the hearing. A provider, CCO or PHP provider, CCO or PHP that is a corporation may be represented by any of the persons identified in ORS 410.190.

(4) Informal conference: Division may notify the provider(s) provider applicant, CCO or PHP provider (and CCO or PHP, if applicable) of the time and place of an informal conference, without the presence of the Administrative Law Judge (ALJ). The purposes of this informal conference are:

(a) To provide an opportunity to settle the matter;

(b) To make sure the parties and the Authority understand the specific reason for the action of the hearing request;

(d) To give the parties and the Authority the chance to correct any misunderstanding of the facts; and

(e) The provider, provider applicant, CCO or PHP provider (or CCO, PHP, if applicable) may, at any time prior to the hearing date, request an additional informal conference with the Division and Authority representative(s), which may be granted if the Division finds at its sole discretion, the additional informal conference will facilitate the Contested Case Hearing process or resolution of disputed issues.

(5) Contested Case Hearing: The Administrative Law Judge (ALJ) will conduct the contested case hearing using the Attorney General's Model Rules at OAR 137-003-0501 to 137-003-0700.

(a) The burden of presenting evidence to support a provider appeal is on the provider, provider applicant, CCO or PHP provider that requested the appeal. Consistent with OAR 410-120-1360, payment on a claim will only be made for services that are adequately documented and billed in accordance with OAR 410-120-1280 and all applicable administrative rules related to covered services for the Client’s benefit package and establishing the conditions under which services, supplies or items are covered, such as the Prioritized List, medical appropriateness and other applicable standards.

(b) Subject to Division approval under OAR 137-003-0525, the ALJ will determine the location of the Contested Case Hearings.

(6) Proposed and Final Orders: The ALJ is authorized to serve a proposed order on all parties and the Division unless prior to the hearing, the Division notifies the ALJ that a final order may be served by the ALJ.

(a) If the ALJ issues a proposed order, and the proposed order is adverse to a party, the party may file written exceptions to the proposed order to be considered by the Division, or the ALJ when the ALJ is authorized to issue the final order. The exceptions must be in writing and received by the Division, or the ALJ when the ALJ is authorized to issue the final order, not later than 10 calendar days after the date of the proposed order is issued by the ALJ. No additional evidence may be submitted without prior approval of Division.

(b) The proposed order issued by the ALJ will become a final order if no exceptions are filed within the time specified in subsection (a) of this rule, unless the Division notifies the parties and the ALJ that Division will issue the final order. After receiving the exceptions or argument, if any, the Division may adopt the proposed order as the final order or may prepare a new order. Prior to issuing the final order, Division may issue an amended proposed order.

(c) Procedures applicable to default orders for withdrawal of a hearing request, failure to timely request a hearing, failure to appear at a hearing, or other default, are governed by the Attorney General’s Model Rules, OAR 137-003-0670 – 137-003-0672.

(d) The final order is effective immediately upon being signed or as otherwise provided in the order.

(7) All Contested Case Hearing decisions are subject to the procedures established in OAR 137-003-675 to 137-003-0700 and to judicial review under ORS 183.482 in the Court of Appeals.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 13-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 73-2003, f. & cert. ef. 10-1-03
OMAP 19-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 41-2000, f. & cert. ef. 12-1-00
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0820
HR 41-1991, f. & cert. ef. 10-1-91
HR 19-1990, f. & cert. ef. 7-9-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0191 & 461-013-0225
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 51-1985, f. 8-16-85, cert. ef. 9-1-85
AFS 37-1984, f. 8-30-44, cert. ef. 9-1-84
AFS 13-1984(Temp), f. & cert. ef. 4-2-84

Or. Admin. R. 410-120-1855 Client’s Rights and Responsibilities

(1) Division of Medical Assistance Programs (Division) clients shall have the following rights:

(a) To be treated with dignity and respect;

(b) To be treated by providers the same as other people seeking health care benefits to which they are entitled;

(c) To refer oneself directly to mental health, substance use disorder or family planning services without getting a referral from a Primary Care Practitioner (PCP) or other provider;

(d) To have a friend, family member, or advocate present during appointments and at other times as needed within clinical guidelines;

(e) To be actively involved in the development of their treatment plan;

(f) To be given information about their condition and covered and non-covered services to allow an informed decision about proposed treatment(s);

(g) To consent to treatment or refuse services, and be told the consequences of that decision, except for court ordered services;

(h) To receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency;

(i) To have written materials explained in a manner that is understandable to the Division client;

(j) To receive necessary and reasonable services to diagnose the presenting condition;

(k) To receive Division covered services that meet generally accepted standards of practice and are medically appropriate;

(L) To obtain covered preventive services;

(m) To receive a referral to specialty providers for medically appropriate covered services;

(n) To have a clinical record maintained that documents conditions, services received, and referrals made;

(o) To have access to one's own clinical record, unless restricted by statute;

(p) To transfer a copy of their clinical record to another provider;

(q) To execute a statement of wishes for treatment, including the right to accept or refuse medical, surgical, substance use disorder or mental health treatment, and the right to execute directives and powers of attorney for health care established under ORS 127 as amended by the Oregon Legislative Assembly 1993 and the OBRA 1990 — Patient Self-Determination Act;

(r) To receive written notices before a denial of, or change in, a benefit or service level is made, unless such notice is not required by federal or state regulations;

(s) To know how to make a Complaint, Grievance or Appeal with the Division and receive a response as defined in OAR 410-120-1860 and 410-120-1865;

(t) To request an Administrative Hearing with the Oregon Health Authority (Authority);

(u) To receive a notice of an appointment cancellation in a timely manner;

(v) To receive adequate notice of Authority privacy practices.

(2) Division clients shall have the following responsibilities:

(a) To treat the providers and clinics’ staff with respect;

(b) To be on time for appointments made with providers and to call in advance either to cancel if unable to keep the appointment or if the client expects to be late;

(d) To use their PCP or clinic for diagnostic and other care except in an Emergency;

(e) To obtain a referral to a specialist from the PCP or clinic before seeking care from a specialist unless self-referral to the specialist is allowed;

(f) To use emergency services appropriately;

(g) To give accurate information, including name that matches the Oregon Health I.D. card for inclusion in the clinical or billing record;

(h) To help the provider or clinic obtain clinical records from other providers which may include signing an authorization for release of information;

(i) To ask questions about conditions, treatments and other issues related to their care that is not understood;

(j) To use information to make informed decisions about treatment before it is given;

(k) To help in the creation of a treatment plan with the provider;

(L) To follow prescribed, agreed-upon treatment plans;

(m) To tell the provider that their health care is covered with the Division before services are received, and to show the provider the Oregon Health I.D.;

(n) To tell the Department or Authority staff of a change of address or phone number;

(o) To tell the Department or Authority staff if the Division client becomes pregnant and to notify the Department worker of the birth of the Division client's child;

(p) To tell the Department or Authority staff if any family members move in or out of the household;

(q) To tell the Department or Authority staff and provider(s) if there is any other insurance available, changes of insurance coverage including Private Health Insurance (PHI) according to OAR 410-120-1960, and to complete required periodic documentation of such insurance coverage in a timely manner;

(r) To pay for non-covered services under the provisions described in OAR 410-120-1200 and 410-120-1280;

(s) To pay the monthly OHP premium on time if so required;

(t) To assist the Division in pursuing any TPR available and to pay the Division the amount of benefits it paid for an injury from any recovery received from that injury;

(u) To bring issues, or Complaints or Grievances to the attention of the Division; and

(v) To sign an authorization for release of medical information so the Authority can get pertinent and needed information to respond to an Administrative Hearing request in an effective and efficient manner.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.066
DMAP 21-2021, amend filed 06/03/2021, effective 06/03/2021
DMAP 71-2013, f. & cert. ef. 12-27-13
Reverted to OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru 12-24-13
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05

Or. Admin. R. 410-120-1860 Contested Case Hearing Procedures

(1) These rules apply to all contested case hearings provided by the Authority involving a client's health care benefits, except as otherwise provided in OAR 410-141-3890. The hearings are conducted in accordance with ORS 183.411 through 183.497 and the Attorney General's model rules, OAR 137-003-0501 through 137-003-0700. When the term "agency" is used in the Attorney General's model rules, it shall refer to the Authority for purposes of this rule except for OAR 137-003-0528(1)(a). The method described in OAR 137-003-0520(8)-(10) is used in computing any period of time prescribed in this division of rules (OAR 410 division 120) applicable to timely filing of client requests for hearing. Due to operational conflicts, the procedures needing revision and the expense of doing so, OAR 137-003-0528(1)(a), which allows hearing requests to be treated as timely based on the date of postmark, does not apply to Authority contested cases.

(2) Medical provider appeals and administrative reviews involving the Division are governed by OAR 410-120-1560 through 410-120-1600.

(3) Grievances, complaints, and appeals for clients requesting or receiving medical assistance from an MCE shall be governed exclusively by the procedures in OARs 410-141-3875 through 410-141-3915. This rule describes the procedures applicable when MCE clients request and are eligible for an Authority contested case hearing.

(4) Contested Case Hearing Requests:

(a) A client has the right to a contested case hearing in the following situations upon the timely completion of a request for a hearing:

(A) The Authority makes an adverse determination or action or, as it relates to an MCE, an adverse benefit determination such as denial of client services, payment of a claim, or to terminate, discontinue, or reduce a course of treatment, or issues related to disenrollment in an MCE; or

(B) The right of a client to request a contested case hearing is otherwise provided by statute or rule, including OAR 410-141-3885 when a client of an MCE may request a state hearing.

(b) To be timely, a request for a hearing is complete when the following requirements are met:

(A) The Authority receives the Authority approved appeal and hearing forms not later than the 60th day following the date of the decision notice;

(B) When enrolled in an MCE, the member files the request for contested case hearing within the time frames specified in OAR 410-141-3900.

(c) In the event a request for hearing is not timely, the Authority shall determine whether the client showed there was good cause, as defined in OAR 137-003-0501(7), for their failure to timely file the hearing request. In determining whether to accept a late hearing request, the Authority requires the request to be supported by a written statement that explains why the request for hearing is late. The Authority may conduct such further inquiry as the Authority deems appropriate. If the Authority finds that the client has good cause for late filing, the Authority shall refer the case to the Office of Administrative Hearings (OAH) for a contested case hearing. The following factual disputes shall be referred to the OAH for a hearing:

(A) Whether the hearing request was received timely;

(B) Whether the client received the notice of adverse benefit determination or action;

(d) In the event the claimant is not entitled to a contested case hearing on an issue, the Authority may enter an order accordingly. The Authority may refer a hearing request to the OAH for a hearing on the question of whether the claimant has a right to a contested case hearing;

(e) A client who requests a hearing shall be referred to as a claimant. The parties to a contested case hearing are the claimant and, if the claimant has requested a hearing about a decision of an MCE, the claimant's MCE;

(f) A client may be represented by any of the individuals identified in ORS 183.458. An MCE that is a corporation may be represented by any of the individuals identified in ORS 410.190.

(g) For clients enrolled in an MCE, the following applies:

(A) May request a contested case hearing with the state after receiving notice that the adverse benefit determination or MCE action is upheld or, in the case of an MCE that fails to adhere to the notice and timing requirements, the state may deem that the member has exhausted the MCE’s appeals process and may initiate a state contested case hearing pursuant to OAR 410-141-3900;

(B) A request for an Authority administrative hearing made prior to an MCE appeal by the member or member’s representative or provider shall be forwarded by the Authority to the MCE for review, except in the case where the Authority determines the MCE failed to act within required timelines.

(5) Expedited hearings:

(a) A claimant who feels their health care problem may not wait for the normal review process may be entitled to an expedited hearing;

(b) A request for an expedited hearing for a service that has already been provided (post-service) to the claimant may not be granted;

(c) Expedited hearings are requested using Authority Form 443 or other Division approved appeal and/or hearing request forms;

(d) Authority staff shall request all relevant health care documentation and present the documentation obtained in response to that request to the Authority medical director or the medical director's designee for review. The Authority medical director or designee shall decide if the claimant is entitled to an expedited hearing within, as nearly as possible, two working days from the date of receiving the documentation applicable to the request;

(e) An expedited hearing shall be allowed if the Authority medical director or the designee determines that the claimant has a health care condition that could jeopardize the claimant’s life, health, or ability to maintain or regain maximum function and claimant has been denied a health care service;

(f) Expedited hearing requests shall be completed as expeditiously as the claimant’s health condition requires with the following timelines:

(A) For members enrolled in an MCE’s the expedited hearing requests responding to any claim requiring review of an MCE written notice of expedited appeal resolution, hearing requests shall be no later than three working days after the agency receives from the MCE the case file and information for any appeal of a denial of a service as indicated by the MCE;

(B) For recipients of Fee For Service the expedited state contested hearing requests, no later than seven working days after the agency receives a request for expedited fair hearing responding to any request for the following reasons:

(i) Claim for services is denied or is not acted upon with reasonable promptness;

(ii) Requests because the claimant believes the agency has taken an action erroneously;

(iii) Requests because the claimant believes a skilled nursing facility or nursing facility has erroneously determined that they must be transferred or discharged;

(iv) Requests because the claimant believes the state has made an erroneous determination with regard to the preadmission and annual resident review requirements of section 1919(e)(7) of the Act; or

(v) For expedited state administrative hearing for claims related to prompt determinations of eligibility and enrollment in the appropriate program without undue delay, consistent with timeliness standards established under CFR §435.912, based on the date the application is submitted to any insurance affordability program.

(g) The Authority shall take final administrative action on a contested hearing request within the time limits set forth in 42 CFR Part 431 and Part 435 except in unusual circumstances when:

(A) The Authority may not reach a decision because the appellant requests a delay or fails to take a required action; or

(B) There is an administrative or other emergency beyond the Authority's control.

(6) Informal conference:

(a) The Authority hearing representative and the claimant, and their legal representative if any, may have an informal conference without the presence of the Administrative law Judge (ALJ) to discuss any of the matters listed in OAR 137-003-0575. The informal conference may also be used to:

(A) Provide an opportunity for the Authority and the claimant to settle the matter;

(B) Provide an opportunity to make sure the claimant understands the reason for the action that is the subject of the hearing request;

(D) Inform the claimant of the rules that serve as the basis for the contested action;

(E) Give the claimant and the Authority the chance to correct any misunderstanding of the facts;

(F) Determine if the claimant wishes to have any witness subpoenas issued for the hearing; and

(G) Give the Authority an opportunity to review its action.

(b) The claimant may at any time prior to the hearing date request an additional informal conference with the Authority representative, which may be granted if the Authority representative finds in their sole discretion that the additional informal discussion shall facilitate the hearing process or resolution of disputed issues;

(d) Any agreement reached in an informal conference shall be submitted to the ALJ in writing or presented orally on the record at the hearing.

(7) A claimant may withdraw a hearing request at any time. The withdrawal is effective on the date it is received by the Authority or the ALJ, whichever is first. The ALJ shall send a Final Order confirming the withdrawal to the claimant's last known address. The claimant may cancel the withdrawal up to the tenth day following the date such an order is effective.

(8) Contested case hearings are closed to non-participants in the hearing; however, a client may choose to have another individual present.

(9) Proposed and Final Orders:

(a) In a contested case, an ALJ assigned by the Office of Administrative Hearings shall serve a proposed order on all parties and the Authority, unless prior to the hearing the Authority notifies the ALJ that a final order may be served. The proposed order issued by the ALJ shall become a final order if no exceptions are filed within the time specified in subsection (b)(A) below, unless the Authority notifies the parties and the ALJ that the Authority shall issue the final order;

(b) If the ALJ issues a proposed order, a party adversely affected by the proposed order may file exceptions to the proposed order or present argument for the Authority’s consideration:

(A) The exceptions must be in writing and reach the Authority not later than ten working days after date the proposed order is issued by the ALJ;

(B) After receiving the exceptions, if any, the Authority may adopt the proposed order as the final order or may prepare a new order. Prior to issuing the final order, the Authority shall issue an amended proposed order.

(10) A hearing request is dismissed by order when neither the party nor the party's legal representative, if any, appears at the time and place specified for the hearing. The order is effective on the date scheduled for the hearing. The Authority shall cancel the dismissal order on request of the party upon the party being able to show good cause, as defined in OAR 137-003-0501(7), as to why they were unable to attend the hearing and unable to request a postponement.

(11) The final order is effective immediately upon being signed or as otherwise provided in the order. A final order resulting from the claimant's withdrawal of the hearing request is effective the date the claimant withdraws. When the claimant fails to appear for the hearing and the hearing request is dismissed by final order, the effective date of the order is the date of the scheduled hearing.

(12) All contested case hearing decisions are subject to judicial review under ORS 183.482 in the Court of Appeals.

[NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 183.341 & 413.042
Statutes/Other Implemented: ORS 183.411 - 183.471, 411.408, 414.025 & 414.065
DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023
DMAP 30-2021, amend filed 07/13/2021, effective 07/22/2021
DMAP 1-2021, minor correction filed 01/14/2021, effective 01/14/2021
DMAP 62-2017, amend filed 12/28/2017, effective 01/01/2018
DMAP 61-2013, f. 10-31-13, cert. ef. 11-1-13
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
DMAP 6-2012(Temp), f. & cert. ef. 2-1-12 thru 7-4-12
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 41-2000, f. & cert. ef. 12-1-00
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 7-1996, f. 5-31-96 & cert. ef. 6-1-96
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0760
HR 34-1991, f. & cert. ef. 8-26-91
HR 11-1991(Temp), f. & cert. ef. 3-1-91
HR 41-1990, f. & cert. ef. 11-26-90
HR 32-1990, f. 9-24-90, cert. ef. 10-1-90
HR 35-1990(Temp), f. & cert. ef. 10-15-90
HR 19-1990, f. & cert. ef. 7-9-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0053
AFS 37-1984, f. 8-30-84, ef. 9-1-84
AFS 13-1984(Temp), f. & ef. 4-2-84
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 47-1982, f. 4-30-82, ef. 5-1-82

Or. Admin. R. 410-120-1865 Denial, Reduction, or Termination of Services

(1) The purpose of this rule is to describe the requirements governing the denial, reduction, or termination of medical assistance and access to the Authority administrative hearings process for clients requesting or receiving medical assistance services paid for by the Authority on a fee-for-service basis. Grievance, complaint, and appeal procedures for clients receiving services from an MCE shall be governed exclusively by the procedures in OAR 410-141-3260 and where applicable OAR 410-141-3475.

(2) When the Authority authorizes a course of treatment or covered service, but subsequently acts (as defined in 42 CFR 431.201) to terminate, suspend, or reduce the course of treatment or a covered service, the Authority or its designee shall mail a written notice to the client at least ten days before the date of the termination or reduction of the covered service unless there is documentation that the client had previously agreed to the change as part of the course of treatment or as otherwise provided in 42 CFR 431.213.

(3) The written client notice must inform the client of the action the Authority has taken or intends to take and reasons for the action; a reference to the particular sections of the statutes and rules involved for each reason identified in the notice; the client’s right to request an administrative hearing; an explanation of the circumstances under which benefits may continue pending resolution of the hearing; and how to contact the Authority for additional information. The Authority is not required to grant a hearing if the sole issue is a federal or state law requiring an automatic change adversely affecting some or all recipients.

(4) The Authority shall have the following responsibilities in relation to continuation or reinstatement of benefit under this rule:

(a) If the client requests an administrative hearing by the tenth day following the date of the client notice, or before the effective date of the action proposed in the notice, if applicable, and requests that the services be continued, the Authority shall continue the services. The service shall be continued until whichever of the following occurs first, but may not exceed ninety days from the date of the client's request for an administrative hearing):

(A) The current authorization expires; or

(B) A decision is rendered about the case that is the subject of the administrative hearing; or

(C) The client is no longer eligible for medical assistance benefits or the health service, supply, or item that is the subject of the administrative hearing is no longer a covered benefit in the client’s medical assistance benefit package; or

(D) The sole issue is one of federal or state law or policy, and the Authority promptly informs the client in writing that services are to be terminated or reduced pending the hearing decision.

(b) The Division shall notify the client in writing that it is continuing the service. The notice shall inform the client that if the hearing is resolved against the client, the cost of any services continued after the effective date of the client notice may be recovered from the client pursuant to 42 CFR 431.230(b);

(A) The Authority takes an action without providing the required notice and the client requests a hearing;

(B) The Authority does not provide the notice in the time required under section (2) of this rule and the client requests a hearing within 10 days of the mailing of the notice of action; or

(C) The post office returns mail directed to the client, but the client's whereabouts become known during the time the client is still eligible for services;

(D) The reinstated services must be continued until a hearing decision, unless at the hearing it is determined that the sole issue is one of federal or state law or policy.

(d) The Authority shall promptly correct the action taken up to the limit of the original authorization, retroactive to the date the action was taken, if the hearing decision is favorable to the client, or the Authority decides in the client's favor before the hearing.

History

Statutory/Other Authority: 413.042
Statutes/Other Implemented: 411.408, 414.025 & 414.065
DMAP 88-2024, minor correction filed 05/01/2024, effective 05/01/2024
DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023
DMAP 34-2023, minor correction filed 04/28/2023, effective 04/28/2023
DMAP 62-2017, amend filed 12/28/2017, effective 01/01/2018
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 30-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-120-1875 Agency Hearing Representatives

(1) Subject to the approval of the Attorney General, an agency officer or employee is authorized to appear (but not make legal argument) on behalf of the Authority in the following classes of hearings:

(a) Contested case hearings requested by clients in accordance with OAR 410-120-1860 and 410-130-1865; and

(b) Contested case hearings involving Providers in accordance with OAR 410-120-1560 to 410-120-1700.

(2) Subject to the approval of the Attorney General, the Authority Audit Manager responsible for the Division of Medical Assistance Programs (Division) audits is authorized to appear (but not make legal argument) on behalf of the Authority in the following classes of hearings:

(a) Division Overpayment determinations made in an audit under OAR 943-120-1505 (Provider audit);

(b) Division Provider Sanction decisions made in conjunction with or in lieu of an overpayment determination in OAR 943-120-1505 (Provider audit).

(3) Legal argument as used in ORS 183.452 and this rule has the same meaning as defined in OAR 137-003-0008(1)(c) and (d) 137-003-0545.

(4) When a Authority officer or employee, or the Authority Audit Manager, represents the Authority, the presiding officer will advise such representative of the manner in which objections may be made and matters preserved for appeal. Such advice is of a procedural nature and does not change applicable law on waiver or the duty to make timely objection. Where such objections involve legal argument, the presiding officer will provide reasonable opportunity for the Authority officer or employee, or the Authority Audit Manager, to consult legal counsel and permit such legal counsel to file written legal argument within a reasonable time after the conclusion of the hearing.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03
OMAP 34-2003, f. & cert. ef. 5-1-03
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
HR 8-1996, f. 5-31-96, cert. ef. 6-1-96

Or. Admin. R. 410-120-1880 Contracted Services

(1) Except as otherwise provided in OAR 410-120-1260 et seq. applicable to provider enrollment or 410-141-3500, 410-141-3700 et seq. governing CCO or PHPs, insurance and service contracts as provided for under ORS 414.115, 414.125, 414.135 and 414.145 may be implemented for covered medical assistance services in any program area(s) of the Oregon Health Authority (Authority) in order to achieve one or more of the following purposes:

(a) To implement and maintain CCO or PHP services;

(b) To ensure access to appropriate Medical Services that would not otherwise be available;

(c) To more fully specify the scope, quantity, or quality of the services to be provided or to specify requirements of the provider or to specify requirements of the Authority in relation to the provider;

(d) To obtain services more cost effectively, (e.g., to reduce the costs of program administration or to obtain comparable services at less cost than the fee-for-service rate).

(2) Contracts, interagency agreements, or intergovernmental agreements under OAR 410-120-1880, subsection (1) funded with federal funds will be subject to applicable federal procurement and contracting requirements, and this rule will be interpreted and applied to satisfy such requirements. To the extent required by the federal funding agency, the Authority will seek prior federal approval of solicitations and/or contracts when the Authority plans to acquire or enhance services or equipment that will be paid in whole or on part with federal funds.

(3) The Authority is exempt from the Public Contracting Code for purposes of source selection pursuant to ORS 279A.025(2). The Authority will use the following source selection procedures when entering into contracts under OAR 410-120-1880, subsection (1). Interagency agreements and intergovernmental agreements are not subject to competitive solicitation as the basis of source selection, and may be selected in accordance with ORS 190.003 to 190.130 and other applicable law or authority. Competition must be used in obtaining contract services to the maximum extent practical, except as otherwise provided in subsection (4) of this rule:

(a) Small procurement procedure may be used for the procurement of supplies and services less than or equal to $10,000. The Authority may use any method reasonably appropriate to the nature of the supply or service and the business needs of the Authority to identify potential contractors;

(b) Informal solicitation procedure may be used for the procurement of services if the estimated cost or contract price is $150,000 or less. Proposals will be solicited from at least three sources, except as otherwise provided in these rules;

(c) Formal solicitation procedure will be used for the procurement of services when the estimated cost or contract price is more than $150,000. Proposals must be solicited as outlined in these rules.

(4) Selection by negotiation may be used in lieu of a competitive procurement under subsection (3) of this rule for the procurement of goods or services if:

(a) The good or service is available only from a single source or the sole source has special skills that are only available based upon his or her expertise or situation. If the Authority Director, or designee, determines that only a single contractor is available or practical for purposes of this rule, the Director or designee may approve selection by negotiation. A memorandum signed by the Director or designee setting forth the reasons for using a sole source contract must be placed in the contract file;

(b) Public need, significant risk of interruption of services, or emergency advises against a delay incident to competitive solicitation. If the Authority Director, or designee, determines that an emergency exists for purposes of this rule, the Director or designee may approve selection by negotiation. A memorandum signed by the Director or designee setting forth the nature of the emergency must be placed in the file;

(c) Compliance with federal requirements necessitated proceeding without competitive solicitation. Documentation of the applicable federal requirements must be placed in the contract file;

(d) Other authority including but not limited to statutory authority in ORS 414.115, 414.125, 414.135, and 414.145, or such other authority, exemptions and delegations of authority that may be applicable to the source selection for the procurement: Documentation of the authority must be placed in the contract file.

(5) A Request for Proposal (RFP) or similar solicitation mechanism must be prepared for contracts for which the Formal Solicitation Procedure will be used. The solicitation document should include at a minimum the following elements, when applicable:

(a) Statement of required work, including a clear description of the services to be provided, standards by which performance of the services will be measured and/or conditions affecting the delivery of services;

(b) Minimum standards and qualifications which contractors must meet to be eligible to provide the services;

(c) Information which the prospective contractors must submit in their proposals to support their capability, such as references and experience providing the same or similar services (when, where, for whom, type of service, etc.);

(d) Funding information and budget requirements;

(e) Information about ownership interests in software or hardware designed, acquired, developed or installed with federal funds, in compliance with federal requirements for ownership, management and disposition;

(f) The form and organization of proposals, when and where proposals are to be submitted, whether late proposals may be considered, and when an award of a contract is expected;

(g) The method and criteria to be used in evaluating proposals and the weighting assigned to each criterion;

(h) Provisions stating how and when the solicitation document must be contested, and how and when the final award must be contested;

(i) Notice that all costs incurred in the preparation of a proposal will be the responsibility of the proposer and will not be reimbursed by the Authority; and

(j) Contract provisions, subject to subsection (8) of this rule.

(6) Proposals must be evaluated in a manner consistent with the evaluation criteria in the solicitation document. A written document stating why the selection was made will be placed in the contract file.

(7) Unless exempt under ORS 291.045 to 291.049 or rules adopted there under, the Authority will obtain the review and approval of the solicitation document, contract or agreement by the Department of Justice.

(8) The terms and conditions of the contract to be awarded to a contractor selected using these source selection rules will be governed by the Public Contracting Code, except for interagency agreements or intergovernmental agreements exempt under ORS 279A.025(2), or contracts or agreements under other exemptions from the Public Contracting Code. The Public Contracting Code, if applicable, and such delegation of authority, if any, as may be made by the Department of Administrative Services to the Authority determine contract approval authority.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.115, 414.125, 414.135, 414.145 & 414.740
DMAP 36-2023, minor correction filed 04/28/2023, effective 04/28/2023
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 11-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 31-1999, f. & cert. ef. 10-1-99
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0580
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0172
AFS 62-1986, f. 8-22-86, ef. 9-1-86

Or. Admin. R. 410-120-1920 Institutional Reimbursement Changes

(1) The Division of Medical Assistance Programs (Division) is required under federal regulations, 42 CFR 447, to submit specific assurances and related information to the Centers for Medicare and Medicaid Services (CMS) whenever it makes a significant change in its methods and standards for setting payment rates for inpatient hospital services or long-term care facilities.

(2) A "significant change" is defined as a change in payment rates that affects the general method of payment to all providers of a particular type or is projected to affect total reimbursement for that particular type of provider by six percent or more during the 12 months following the effective date.

(3) Federal regulation specifies that a public notice must be published in one of the following:

(a) A state register similar to the Federal Register. For the Oregon Health Authority (Authority), the state register is the Oregon Bulletin published by the Secretary of State;

(b) The newspaper of widest circulation in each city with a population of 50,000 or more;

(d) The Authority web site for public notices.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0380
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0006
AFS 13-1985, f. 3-4-85, ef. 4-1-85

Or. Admin. R. 410-120-1940 Interest Payments on Overdue Claims

(1) Upon request by the provider, the Division will pay interest on an overdue claim:

(a) A claim is considered “overdue” if Division does not make payment within 45 days of receipt of a valid claim;

(b) The interest rate shall be the usual rate charged by the provider to the provider’s clientele, but not more than 2/3 percent per month or eight percent per year.

(2) When billing Division for interest on an overdue valid claim the provider must furnish the following information in writing:

(a) Name of the service and the location the service was provided;

(b) The name of the client who received the service;

(d) Date of service;

(e) Date of initial valid billing of the Division;

(f) Amount of billing on initial valid claim;

(g) Division Internal Control Number (ICN) of claim;

(h) Certification, signed by the provider or the provider’s authorized agent, that the amount claimed does not exceed the usual overdue account charges assessed by the provider to the provider’s clientele.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 37-2023, minor correction filed 04/28/2023, effective 04/28/2023
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 42-2002, f. & cert. ef. 10-1-02
OMAP 31-1999, f. & cert. ef. 10-1-99
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0360
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0185
AFS 24-1985, f. 4-24-85, ef. 6-1-85
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 47-1982, f. 4-30-82, ef. 5-1-82

Or. Admin. R. 410-120-1960 Payment of Private Insurance Premiums

(1) Private Insurance Premium (PHI) and Health Insurance Premium Payment (HIPP) are cost saving programs administered by the Authority and the Department for Medicaid enrollees. When a Medicaid client or eligible enrollee is covered by employer sponsored group health insurance or private health insurance, the Authority or Department may choose to reimburse all or a portion of the insurance premium, if it is determined to be cost effective for the Authority or Department.

(2) The Authority or Department may pay health insurance policy premiums or otherwise enter into agreements with other health insurance plans that comply with ORS 414.115 to 414.145 on behalf of eligible individuals when:

(a) The client is enrolled in a full coverage Medicaid program approved by the Authority or Department (excluding CHIP and CWM);

(b) The policy is a comprehensive major medical insurance plan (comparable to the Medicaid State Plan coverage) and at a minimum provides the following:

(A) Physician services;

(B) Hospitalization (inpatient and outpatient);

(D) Full prescription drug coverage.

(c) The payment of premiums, co-insurance, and deductibles is likely to be cost-effective, as determined under section (5) of this rule;

(d) An eligible applicant may be a non-Medicaid individual living in or outside the household. The Authority or Department may pay the entire premium (excluding the employer’s portion) if payment of the premium including the non-Medicaid individual is cost-effective and if it is necessary to include that individual in order to enroll the client in the health plan.

(3) The Authority or Department shall not pay private health insurance premiums for:

(a) Non-SSI institutionalized and waivered clients whose income deduction is used for payment of health insurance premiums;

(b) A policy that has limited benefits where the Authority or Department’s annual cost for the premiums exceeds the benefit limits of the policy;

(d) Non-major medical stand-alone policies such as dental, vision, cancer, or accident only;

(e) When the purpose of the policy is providing court ordered health insurance.

(4) The Authority or Department shall assure that all Medicaid covered services continue to be made available to Medicaid-eligible individuals for whom the Authority or Department elects to purchase all or a portion of their private or employer-sponsored health insurance.

(5) Assessment of cost-effectiveness shall include:

(a) The Medical Savings Chart (MSC) is used to obtain the cost effectiveness rate for each Medicaid eligible client;

(b) In cases where there is more than one Medicaid eligible client covered by a single insurance policy, the cost effectiveness rates are combined and compared to the cost of the insurance premium. If the combined cost effectiveness rate total is greater than the cost of the premium, it is approved as cost effective;

(c) If the monthly premium exceeds the allowable amount on the MSC, the Authority or Department may elect to review the current and probable future health status of the Medicaid client based upon their existing medical conditions, previous medical history, age, number of dependents, and other relevant health status indicators. The Authority or Department may apply a special conditions rate in addition to the cost-effectiveness rate on the MSC to determine if their premium is cost effective.

(6) The Authority or Department may purchase documents or records necessary to establish or maintain the client's eligibility for other insurance coverage.

(7) The Authority or Department may not make payments for any benefits covered under the private health insurance plan except as follows:

(a) The Authority or Department shall calculate the allowable payment for a service. The amount paid by the other insurer shall be deducted from the allowable. If the allowable exceeds the third party payment, the Authority or Department shall pay the provider of service the difference;

(b) The payment may not exceed any co-insurance, copayment, or deductible due;

(c) The Authority or Department shall make payment of co-insurance, copayments, or deductibles due only for covered services provided to Medicaid eligible clients.

(8) Any change of insurance coverage shall be reported to the Authority or Department within ten days of the change. If the Authority or Department determines reimbursement of premiums was made on behalf of the client for a policy no longer in effect, the payee shall be liable for repayment to the Authority or Department for the full amount of any overpayment established. To minimize any overpayment made on the client’s behalf, changes that must be reported include but are not limited to:

(a) Private or employer-sponsored insurance no longer active;

(b) Family member added or dropped from health insurance plan;

(d) Change in employer resulting in change in health insurance plan;

(e) Change in health plan premium cost;

(f) Change in employment status (lay off or termination, short-term disability);

(g) Address changes.

(9) As a condition of eligibility, clients must pursue assets (OAR 461-120-0330) and obtain medical coverage (OAR 461-120-0345). Failure to notify the Authority or Department of insurance coverage or changes in coverage and failure to provide periodic required documentation for PHI/HIPP may impact continued eligibility.

(10) If it is determined that reimbursement of premiums is cost-effective, payments shall begin in the next new month following the determination; however, the Authority or Department may approve a retroactive payment when appropriate.

(11) Cancellation of premium payment shall result when:

(a) A client is no longer eligible for a medical program approved by the Authority or Department;

(b) A client is no longer covered by the employer-sponsored or private health insurance plan;

(d) Failure to submit or complete redetermination forms or provide documentation required by the Authority or Department to complete redetermination;

(e) A client or eligible applicant fails to use the Authority or Department’s premium payment reimbursement to pay for their private insurance, if they are required to pay the insurance directly;

(f) The policy-type changes (primary policy changes to a supplemental policy) or the client’s eligibility changes to a category that does not meet the requirements in section (2).

(12) The Authority or Department shall determine where approved premium payments shall be sent to: the policy holder (or authorized representative), the employer, insurance carrier, or some other entity.

(13) The client or eligible applicant’s receipt of payment under this rule is intended for the express purpose of insurance premium payment or reimbursement of client-paid insurance premium. If insurance is canceled because payment was used for purposes other than premium payment, an overpayment may occur.

(14) Redetermination for HIPP/PHI reimbursement shall occur:

(a) Annually for continued cost effectiveness and may also be reviewed more frequently to ensure insurance is active;

(b) When changes with medical program, insurance eligibility, or employment have been reported or identified;

(15) Payment of premiums is a reimbursement and not a medical benefit; therefore, clients do not have hearing rights for a denial of private insurance premium payment. The Authority or Department’s decision to place a client in the PHI/HIPP program is a reimbursement and not an eligibility determination nor denial of a medical program benefit.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065, 414.115, 414.125, 414.135 & 414.145
DMAP 26-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 40-2015, f. & cert. ef. 7-1-15
DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12
OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0500 & 410-120-0520
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0170
AFS 38-1984, f. 8-30-84, ef. 9-1-84
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 47-1982, f. 4-30-82, ef. 5-1-82

Or. Admin. R. 410-120-1980 Requests for Information and Public Records

(1) The Division of Medical Assistance Programs (Division) will make non-exempt public records available for inspection to persons making a public records request under ORS 192.410 to 192.500.

(2) Division may charge a fee for copies of non-exempt public records to cover actual costs per OAR 943-003-0010.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 192.410 - 192.505
DMAP 3-2007, f. & cert. ef. 6-1-07
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
HR 32-1993, f. & cert. ef. 11-1-93

Or. Admin. R. 410-120-1990 Telehealth

(1) The following definitions apply to the Oregon Health Authority (Authority) administrative rules applicable to the medical assistance programs:

(a) “Asynchronous” means not simultaneous or concurrent in time. For the purpose of this general rule, asynchronous telecommunication technologies for telehealth services may include audio and video, audio without video, client or member portal and may include remote monitoring. “Asynchronous” does not include voice messages, facsimile, electronic mail or text messages;

(b) “Audio only” means the use of audio technology, permitting real-time communication between a health care provider and a member for the purpose of diagnosis, consultation or treatment. “Audio only” does not include health services that are normally delivered by audio telephone technology and normally not billed as separate services by a health care provider, such as the sharing of laboratory results;

(e) “Telecommunication technologies” means the use of devices and services for telehealth delivered services. These technologies include videoconferencing, store-and-forward imaging, streaming media including services with information transmitted using landlines, and wireless communications, including the Internet and telephone networks;

(f) “Telehealth” includes telemedicine and also includes the use of electronic information and telecommunications technologies to support remote clinical healthcare, client or member and professional health-related education, public health, and health administration;

(g) “Telemedicine” means the mode of delivering remote clinical health services using information and telecommunication technologies to provide consultation and education or to facilitate diagnosis, treatment, care management or self-management of a client or member’s healthcare;

(h) “Trauma informed approach” as defined in OAR 410-120-0000;

(i) “Trauma informed services” as defined in OAR 410-120-0000.

(2) Communications may be between providers, or between one or more providers and one or more clients or members, family members, caregivers and guardians.

(3) School-Based Health Services required by the Individuals with Disabilities Education Act (IDEA), Section 504 Plan, under the Rehabilitation Act of 1973, or any other documented individualized health or behavioral health plan or as otherwise determined medically necessary provided in school programs and settings provided to eligible children in their education program settings by public education enrolled providers billing for these services to Medicaid are exempt from this rule. See chapter 410, division 133 for School-Based Health Services OARs.

(4) CCOs and FFS providers must ensure Oregon Health Plan (OHP) clients or members are offered a choice of how services are received, including services offered using telehealth modalities and in-person services, except where the Authority issues explicit guidance during a declared state of emergency or if a facility has implemented its facility disaster plan.

(5) Providers unable to offer in-person services:

(a) FFS providers unable to offer in-person services must develop, maintain and carry out policies and procedures to offer local provider options to a client or member when an in-person visit is clinically indicated or when the client or member requests in-person services. This may include but is not limited to care coordination or completing referral paperwork;

(b) CCOs must ensure that providers unable to offer in-person services have access to the CCO Provider Directory. CCOs must include in applicable provider contract language that providers unable to offer in-person services shall, as needed, inform the CCO upon referring a member to another provider so the CCO can provide any care coordination services necessary to support the member in accessing care.

(6) Client or member choice and accommodation for telehealth must encompass the following standards and services:

(a) Providers who offer telehealth delivered services must offer meaningful access to services by completing a capacity assessment of the client or member in the use of specific approved methods of telehealth delivery that comply with accessibility standards including alternate formats, and provides the optimal quality of care for the client or member given considerations of client or member access to necessary devices, access to a private and safe location, adequate internet, digital literacy, cultural appropriateness of services delivered using telehealth, and other considerations of client or member readiness to use telehealth;

(b) Providers must offer meaningful access to health care services for clients or members and their families who experience Limited English Proficiency (LEP) or hearing impairment by working with qualified or certified health care interpreters, to provide language access services as described in OAR 333-002-0040. These services must not be significantly restricted, delayed, or inferior as compared to programs or activities provided to English proficient individuals;

(c) Providers must collaborate with clients or members to identify and offer modalities for delivering health care services which best meets the needs of the member and considers the client or member’s choice and readiness for the modality of service selected;

(d) Providers must offer telehealth services which are consistent with “meaningful access” as defined in OAR 410-120-0000.

(7) Privacy and security standards for telehealth services must be met by satisfying the following:

(a) Prior to the delivery of services using a telehealth modality, a client or member’s written, oral, or recorded consent to receive services using a telehealth delivery method in the language that the client or member understands must be obtained and documented by the health system, clinic or provider in the client or member’s health record. Consent must include an assessment of client or member readiness to access and participate in telehealth delivered services, including conveying all other options for receiving the health care service to the client or member. Consent must be updated at least annually thereafter. For clients or members and their families who experience LEP or hearing impairment clients, providers must use qualified or certified health care interpreters when obtaining client or member consent;

(b) Consistent with Oregon Revised Statute (ORS) 109.640, provision of birth control information and services using a telehealth modality must be provided to any person regardless of age without consent of parent or legal guardian;

(c) Consistent with ORS 109.640, provision of any other medical or dental diagnosis and treatment using a telehealth modality must be provided to any person 15 years of age or older without consent of parent or legal guardian;

(d) Consistent with ORS 109.675, provision of outpatient diagnosis or treatment of a mental or emotional disorder or a chemical dependency using a telehealth modality must be provided to any person 14 years of age or older without consent of parent or legal guardian;

(e) Consistent with ORS 109.610, provision of diagnosis or treatment of certain sexually transmitted infections using a telehealth modality must be provided to a person regardless of age without consent of parent or legal guardian;

(f) Services provided using a telehealth platform must comply with Health Insurance Portability and Accountability Act (HIPAA), https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996, and with the Authority’s Privacy and Confidentiality Rules (chapter 943, division 14) except as noted in section (10) below;

(g) There is no limitation on the location of the client or member;

(h) OHP enrolled providers may be located in any location where client or member privacy and confidentiality can be ensured;

(i) Persons providing interpretive services and supports must be in a location where client or member privacy and confidentiality can be ensured.

(8) Providers who offer telehealth delivery of services must meet the following requirements:

(a) Must hold an unencumbered Oregon license;

(b) Must be enrolled with the Authority as an Oregon Health Plan (OHP) provider, per OAR 410-120-1260;

(c) Must provide services using telehealth that are within their respective certification or licensing board’s scope of practice and comply with telehealth requirements including, but not limited to:

(A) Documenting client or member and provider agreement of consent to receive services.

(B) Allowed physical locations of provider and client or member.

(d) Comply with HIPAA and the Authority’s Privacy and Confidentiality Rules and security protections for the member in connection with the telehealth communication and related records requirements (OAR chapter 943 division 14 and 120, OAR 410-120-1360 and 1380, 42 CFR Part 2, if applicable, and ORS 646A.600 to 646A.628 (Oregon Consumer Identity Theft Protection Act) except as noted in section (10) of this rule;

(e) Obtain and maintain technology used in telehealth communication that is compliant with privacy and security standards in HIPAA and the Authority’s Privacy and Confidentiality Rules described in subsection (A) except as noted in section (10) of this rule;

(f) Develop and maintain policies and procedures to prevent a breach in privacy or exposure of client or member health information or records (whether oral or recorded in any form or medium) to unauthorized persons and timely breach reporting as described in OAR 943-014-0440;

(g) Maintain clinical and financial documentation related to telehealth services as required in OAR 410-120-1360 and any program specific rules in OAR chapter 309 and chapter 410;

(h) Comply with all federal and state statutes as required in OAR 410-120-1380.

(9) CCOs and the Authority will reimburse telehealth delivered services only when all the following requirements are met:

(a) Services provided must be covered services according to the client or member's benefit package as described in OAR 410-120-1210 and be provided in a manner compliant with relevant guideline notes included in the Health Evidence Review Commission’s Prioritized List of Health Services as described in OAR 410-141-3830;

(b) CCOs and the Authority must provide reimbursement for telehealth services at the same reimbursement rate as if the professional services were provided in person.

(A) As a condition of reimbursement, FFS providers must agree to reimburse Certified and Qualified Health Care Interpreters (HCIs) as defined in OAR 333-002-0010 for interpretation services provided using telehealth at the same rate, excluding travel expenses, as if interpretation services were provided in-person.

(B) CCOs must also reimburse Certified and Qualified HCIs for interpretation services provided using telehealth at the same reimbursement rate, excluding travel expenses, as if it were provided in person. These requirements do not supersede the CCOs direct agreement(s) with providers, including but not limited to, alternative payment methodologies, quality and performance measures or Value Based Payment methods described in the CCO contract. Administrative rules and CCO Direct Agreements do not supersede any federal or state requirements with regard to the provision and coverage of health care interpreter services.

(c) When allowed by individual certification or licensing board’s scope of practice standards, qualifying telehealth delivered services are covered:

(A) When provided to established clients or members;

(B) When provided to new clients or members; and

(d) All physical, behavioral and dental telehealth services except School Based Health Services (SBHS) must include Place of Service code 02 when the client or member is located in a place other than their home. When the client or member is located in their home, the claim must include Place of Service code 10;

(e) All claim types except dental services must include modifier 95 when the telehealth delivered service utilizes a real-time interactive audio and video telecommunication system. When provision of the same service utilizes a real-time interactive audio only, the claim must include modifier 93.

(10) In the event of a declared emergency or changes in federal requirements, the Authority may adopt flexibilities to remove administrative barriers and support telehealth delivered services:

(a) The Authority must follow guidance from the US Department of Health and Human Services (HHS) Office for Civil Rights (OCR), which may allow enforcement discretion related to privacy or security requirements.

(b) The Authority may expand network capacity through remote care and telehealth services provided across state lines.

History

Statutory/Other Authority: ORS 413.032 & 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.723
DMAP 39-2025, amend filed 04/25/2025, effective 04/25/2025
DMAP 97-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 75-2023, amend filed 09/13/2023, effective 09/13/2023
DMAP 47-2023, minor correction filed 06/05/2023, effective 06/05/2023
DMAP 1-2022, amend filed 01/05/2022, effective 01/05/2022
DMAP 64-2020, adopt filed 12/18/2020, effective 01/01/2021

Or. Admin. R. 410-120-2000 HRSN Services Delivery

The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering and delivering Health Related Social Needs (HRSN) Services.

(1) HRSN Services General Requirements; Overview of Administration and Delivery of HRSN Services. HRSN Services (defined in OAR 410-120-0000) are similar to Covered Services, but approval for receiving HRSN Services is not subject to the Medically Necessary and Appropriate standard required for Covered Services. Instead, in order for a Member to receive HRSN Services, the HRSN Service must be determined to be Clinically Appropriate (defined in OAR 410-120-0000).

(2) HRSN Services are included in OHP Plus benefit package and are paid for on an encounter basis.

(3) MCEs and HRSN Service Providers shall be compensated for the provision of HRSN Services in accordance with the HRSN Services Fee Schedule. The state must review the HRSN Fee Schedule at least once (1) every calendar year to determine whether changes need to be made as determined by the Authority in its sole discretion. Subject to the Authority’s reasonable discretion and applicable law, MCEs and HRSN Service Providers shall be compensated for HRSN Services on an encounter basis or incorporated into capitation rates.

(4) MCEs and, as applicable, the Authority must provide Members with the same notices required to be provided for all other Covered Services, including, without limitation, Service Authorizations in accordance with 42 CFR 435.917, OAR 410-141-3835, and OAR 410-120-2020, and notices of Adverse Benefit Determination (ABD).

(a) MCEs, and as applicable, the Authority shall notify all Members of the availability of HRSN Services, the process by which they may obtain an HRSN Eligibility Screening, and the standards for authorization of HRSN Services in their Member communications, in accordance with OAR 410-120-2020 and OAR 410-141-3585.

(b) All notices must comply with accessibility requirements as required by 42 CFR 438.10, and OARs 410-141-3580 and 410-141-3585.

(d) All notices of Adverse Benefit Determinations (ABDs) must comply with 42 CFR §438.404, OAR 410-141-3885, 42 CFR §435.917 and OAR 410-120-1860 and include information that tells Members about their Grievance and Appeal rights under 42 CFR Part 438, Subpart F, OARs 410-141-3875 through 410-141-3915, 42 CFR 435.917, and OAR 410-120-1860.

(5) HRSN Services administration and delivery consists of a number of tasks and activities which are required to be delivered by the HRSN Service Provider and MCE, or Authority, in accordance with the following administrative rules:

(a) Identifying HRSN Eligible Members and conducting Outreach and Engagement of Members that complies with requirements detailed in OAR 410-120-2005 Tables 7 and 10;

(b) Accepting requests for HRSN Services that comply with OAR 410-120-2010;

(c) HRSN Eligibility Screening, Service Authorization, referring to an HRSN Service Provider, and ensuring delivery of an HRSN Service that complies with OAR 410-120-2005, OAR 410-120-2015, and OAR 410-120-2020;

(d) Developing an HRSN Person-Centered Service Plan that complies with OAR 410-120-2025; and

(e) Contracting with HRSN Service Providers that meet qualifications in compliance with OAR 410-120-2030.

(f) Coordinating Member’s HRSN services in accordance with OAR 410-141-3860, OAR 410-141-3865, and OAR 410-141-3870 including during the following situations:

(A) In the event a Member is disenrolled from their MCE and enrolled in a new MCE or with the Authority, and the Member has been screened and authorized for, but not yet received, an HRSN Service, or was receiving HRSN services at the time of their disenrollment and wishes to receive or continue to receive the authorized service, the new MCE, or as applicable, the Authority, must accept HRSN Eligibility Screening information used and provided by the predecessor MCE to conduct their own review as expeditiously as the Member’s circumstances require. In no event may the time for review exceed seven (7) calendar days following the receipt of the predecessor MCE’s information.

(i) If it is determined by the new MCE or as applicable, the Authority, that the Member is still eligible for the HRSN service and wishes to receive it, the new MCE or as applicable, the Authority, must authorize and provide the HRSN service as expeditiously as the Member’s circumstances require, in accordance with OAR 410-120-2020.

(ii) If it is determined by the new MCE or as applicable, the Authority, that the Member is no longer eligible for the HRSN service, the new MCE or as applicable, the Authority, must deny the HRSN service in accordance with OAR 410-120-2020.

(B) In situations described in 5(f)(A) of this rule, to ensure continuity of care, the predecessor MCE or as applicable, the Authority, must provide the new MCE, or as applicable, the Authority, with the HRSN Eligibility Screening information used to support the HRSN service authorization and provision of HRSN service for the now-former Member. This information must be provided to the new MCE, or as applicable, the Authority, as expeditiously as the Member’s circumstances require, and no later than seven (7) calendar days following the Member’s disenrollment and receipt of the new MCE’s or Authority’s request for HRSN Eligibility Screening information.

(C) In situations described in 5(f)(A), the new MCE or as applicable, the Authority, must avoid conducting unnecessary and redundant HRSN Eligibility Screenings and making requests to Members for documentation, if the predecessor MCE or the Authority is able to provide sufficient documentation to support the authorization and service provision of the HRSN service by the new MCE, or as applicable, the Authority.

(6) HRSN Services delivered by the MCE, the Authority, or an HRSN Service Provider, shall be culturally and linguistically appropriate, responsive, and trauma-informed in accordance with National CLAS Standards and Trauma-Informed Care principles.

(7) MCE and as applicable, the Authority, shall protect against conflicts of interest in the administration and delivery of HRSN Services.

(a) An MCE and, as applicable, the Authority shall not deliver any HRSN Service that it has authorized unless the MCE can demonstrate it is the only willing and qualified organization that is capable of providing the HRSN Service to the HRSN Authorized Member within the service provision timelines described in OAR 410-120-2020.

(b) The MCE and as applicable, the Authority must devise conflict of interest protections including separation of authorization and HRSN Service Provider functions within the MCE and as applicable, the Authority.

(c) The conflict of interest protections devised by the MCE must be documented and is subject to the approval of the Authority, and must be retained and provided if requested for Authority audit or other review.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.632, 414.665 & 414.719
DMAP 97-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 130-2024, amend filed 10/24/2024, effective 11/01/2024
DMAP 118-2024, amend filed 08/26/2024, effective 08/26/2024
DMAP 35-2024, adopt filed 01/22/2024, effective 01/22/2024

Or. Admin. R. 410-120-2005 Temporary rule language in effect until 10/27/2026. HRSN Service Eligibility; Identifying HRSN Eligible Members; HRSN Outreach and Engagement Services.

(1) A Member is authorized to receive HRSN Services so long as they meet the definition of HRSN Eligible in OAR 410-120-0000 and all other eligibility requirements applicable to the specific HRSN Service requested by the Member or Member Representative, all of which are identified in Tables 1 through 10 of this rule.

(2) A Member is not eligible for a requested HRSN Service if any of the following applies:

(a) The Member is not eligible for the OHP Plus benefit package as described in 410-120-1210;

(b) The Member is already receiving the same service from a different state, local, or federal agency, organization, or entity, according to existing information held by the MCE or the Authority, or by Member Self-Attestation. If a Member is receiving a similar service as the requested HRSN, the requested HRSN Services may be provided to the Member so long as they meet all eligibility criteria for the requested HRSN Service and the amount and duration of the HRSN Services is in an amount that may fill the gaps of or otherwise supplement the deficiencies in the similar service the Member is receiving;

(c) The Member does not meet all other eligibility criteria for the specific HRSN Service requested, all of which are identified in Tables 4 through 10 of this rule, OAR 410-120-2005.

(3) Identifying Members Potentially Eligible for HRSN Services: The MCE and the Authority shall ensure multiple pathways for Members to be identified as potentially eligible for HRSN Services. Pathways for identifying potentially eligible Members for HRSN Services at a minimum must include the following:

(a) Proactively identifying Members who can be Presumed HRSN Eligible through a review of the MCE or Authority’s encounter and claims data;

(b) Contracting with HRSN Service Providers to conduct HRSN Outreach and Engagement (O&E) to identify Members;

(c) Engaging with and receiving HRSN Requests (outlined in OAR 410-120-2010) from HRSN Connectors (defined in OAR 410-120-0000), including HRSN Service Providers;

(d) Regardless of whether a contractual relationship exists, conducting proactive outreach to HRSN Service Providers, especially HRSN Housing Service Providers, for the purpose of encouraging communication with Members who may be eligible for and benefit from HRSN Services; and

(e) Accepting Members’ referrals or Self-Attestations, as applicable.

(f) MCEs and the Authority may scale up or down the Member identification efforts described in subsections (a)-(d) of this section (3) if the Member self-referral or Self-Attestations described in subsection (e) of this section (3) results in sufficient numbers of HRSN Eligible individuals requesting and being screened for HRSN Services.

(4) HRSN Outreach and Engagement Services and Compensation.

(a) MCEs, the Authority, and HRSN Service Providers shall provide the HRSN Outreach and Engagement Services (HRSN O&E Services) described in Table 7 of this rule to Members who are Presumed HRSN Eligible, HRSN Eligible, and HRSN Authorized Members as described in OAR 410-120-0000 and Table 10 of this rule.

(b) HRSN O&E Service Providers must be compensated by the MCE, or, as applicable the Authority for providing HRSN O&E Services described in Table 7 of this rule to:

(A) HRSN Eligible Members;

(B) Members who are confirmed to be enrolled in OHP (FFS or an MCE) and are Presumed HRSN Eligible Members as defined in OAR 410-120-0000; or

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632
DMAP 16-2026, temporary amend filed 05/05/2026, effective 05/05/2026 through 10/27/2026
DMAP 14-2026, temporary amend filed 04/28/2026, effective 05/01/2026 through 10/27/2026
DMAP 97-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 28-2025, temporary amend filed 02/12/2025, effective 02/14/2025 through 06/29/2025
DMAP 144-2024, temporary amend filed 12/29/2024, effective 01/01/2025 through 06/29/2025
DMAP 130-2024, adopt filed 10/24/2024, effective 11/01/2024

Or. Admin. R. 410-120-2010 Temporary rule language in effect until 10/27/2026. HRSN Service Requests

(1) MCEs and the Authority shall accept and document all requests for HRSN Services (“HRSN Request(s)”) received through the pathways identified in OAR 410-120-2005 which utilize the methods described in section (11) of this rule. MCEs and the Authority shall accept, document, and receive all Self-Attestations for HRSN Services in the same manner as it accepts, documents, and receives all other HRSN Requests.

(2) MCEs and the Authority shall accept HRSN Requests from HRSN Connectors, that are not HRSN Service Providers, in writing or via telephone (or both). With the exception of HRSN Medically Tailored Meals, HRSN Home Changes for Safety, and HRSN Rent and Utility Financial Assistance, all other HRSN Requests made to the MCE or, as applicable, the Authority shall be effective when made:

(a) By telephone upon documenting all of the information in subsection (c) of this section (2). Documentation must be made during the telephone call or immediately thereafter; or

(b) In writing by the HRSN Connector and delivered to the MCE or, as applicable the Authority, provided that the writing includes all of the information described in subsection (c) of this section (2).

(c) An HRSN Request submitted by HRSN Connectors must be documented in writing as described in subsections (a) or (b) of this section (2) and include all of the following information:

(A) The name and contact information for the individual recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority, in accordance with OAR 410-120-2015.

(3) HRSN Requests for Medically Tailored Meals made by HRSN Connectors that are not HRSN Service Providers shall be effective when the MCE, or as applicable, the Authority, has collected all of the information in subsections (a) and (b) of this section (3):

(a) The information identified in this subsection (a) must be collected in writing or may be collected during a telephone call. If the information is collected during a telephone call, the information must be documented by the MCE or, as applicable, the Authority, during or immediately after the telephone call.

(A) Name and contact information for the individual recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority; and

(b) The following must be obtained in writing:

(A) An assessment conducted by a Registered Dietitian Nutritionist licensed in the state of Oregon (RDN) indicating that Medically Tailored Meals are Medically Necessary and Medically Appropriate for the individual together with a Nutrition Care Plan; or

(B) An assessment and Nutrition Care Plan may be provided by a primary care physician or a physician specialist such as a cardiologist or oncologist when access to an RDN is limited or delayed.

(4) HRSN Requests for Rent and Utility Financial Assistance made by an HRSN Connectors that are not HRSN Service Providers, shall be effective when the MCE, or as applicable, the Authority, has collected the information in subsections (a) and (b) of this section (4):

(A) The name and contact information for the individual recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority; and

(D) Income verification to determine “At Risk of Homelessness” as defined in OAR 410-120-0000. Income verification may be self-attested to as described in OAR 410-120-2015; and

(b) A copy of the written lease, HRSN Verification of Landlord/Tenant Relationship and Rent Owed form, or rental agreement as described in OAR 410-120-2005 Table 5 must be obtained.

(5) HRSN Requests for Home Changes for Safety (Home Modifications and Remediations) made by HRSN Connectors that are not HRSN Service Providers shall be effective when the MCE, or as applicable, the Authority, has collected the information in subsections (a) and (b) of this section (5) as follows:

(A) The name and contact information for the individual recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority.

(b) The following information must be provided to, or collected by, the MCE or, as applicable, the Authority, in writing:

(A) A completed scope of work must be submitted to the MCE or the Authority as appropriate, as detailed in OAR 410-120-2005 Table 5; and

(B) If the Member rents their home, the landlord must provide written consent to the service, which shall also serve as verification that the individual lives at the residence; or

(C) If the Member owns their home, the Member must provide proof of homeownership (for example, Certificate of Title/Deed, Monthly mortgage bill).

(6) With the exception of HRSN Medically Tailored Meals, HRSN Home Changes for Safety, and HRSN Rent and Utility Financial Assistance, HRSN Requests made by an HRSN Connector that is also an HRSN Service Provider must be in writing and:

(a) Must include all of the following:

(A) Name and contact information for the individual being recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority, which must be signed or orally attested to by the individual for whom the request is being made or the individual’s Representative; and

(b) May include any one or all of the following:

(A) Confirmation of individual’s current OHP enrollment;

(B) Confirmation of current enrollment in the MCE or in FFS;

(7) HRSN Requests for Medically Tailored Meals made by an HRSN Connector that is also an HRSN Service Provider must be in writing and:

(a) Must include all of the following:

(A) Name and contact information for the individual being recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority, which must be signed or verbally attested to by the individual for whom the request is being made or the individual’s Representative; and

(D) Registered Dietitian Nutritionist (RDN) assessment (or Primary Care Provider (PCP) if RDN access is limited or delayed) indicating that Medically Tailored Meals are Medically Appropriate and Medically Necessary for the individual; and

(E) Nutrition Care Plan; and

(b) May include any one or all of the following:

(A) Confirmation of individual’s current OHP enrollment;

(B) Confirmation of current enrollment in the MCE or in FFS;

(8) HRSN Requests for Rent and Utility Financial Assistance made by HRSN Connectors that are also HRSN Service Providers, must be in writing and:

(a) Must include all of the following:

(A)The name and contact information for the individual recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority; and

(D) A written lease, HRSN Verification of Landlord/Tenant Relationship and Rent Owed form, or rental agreement as described in OAR 410-120-2005 Table 5; and

(E) Income verification to determine “At Risk of Homelessness” as described in OAR 410-120-0000. Income verification may be self-attested to as described in OAR 410-120-2015; and

(b) May include any one or all of the following:

(A) Confirmation of individual’s current OHP enrollment;

(B) Confirmation of current enrollment in the MCE or in FFS;

(9) HRSN Requests for HRSN Home Changes for Safety (Home Modifications and Remediations) made by an HRSN Connector that is also an HRSN Service Provider must be in writing and:

(a) Must include all of the following:

(A) The name and contact information for the individual recommended; and

(B) The HRSN Service(s) the individual needs or may need; and

(C) A statement that the individual desires to take part in an HRSN Eligibility Screening performed by the MCE, or as applicable, the Authority; and

(D) If the Member rents their home, the landlord must provide written consent for home modification services, which shall also serve as verification that the individual lives at the residence. If the Member rents their home, and the lease/rental agreement requires landlord approval of any home remediations that will be made, the landlord must provide written consent to the service, which also may serve as the verification that the individual lives at the residence. If the Member rents their home and the lease agreement does not require landlord approval for home remediations, the Member must submit proof of residency. If the Member owns their home, the Member must provide proof of homeownership (for example, Certificate of Title/Deed); and

(E) A completed scope of work must be submitted to the MCE or the Authority as appropriate, as detailed in OAR 410-120-2005 Table 5; and

(b) May include any one or all of the following:

(A) Confirmation of individual’s current OHP enrollment;

(B) Confirmation of current enrollment in the MCE or in FFS;

(10) MCEs and the Authority shall accept complete HRSN Requests from an HRSN Connector that complies with the requirements in this rule. Complete HRSN Requests that comply with the requirements of this rule are subject to the service authorization timeframes identified in OAR 410-120-2020 regardless of whether they are submitted by a Member, HRSN Service Provider, or any other HRSN Connector.

(11) At a minimum, all MCEs and the Authority shall accept HRSN Requests received from an HRSN Connector that uses any of the following delivery methods: email, mail, or personal delivery. MCEs and the Authority may choose to accept other reliable delivery methods, including but not limited to, community information exchange (CIE) and telephone. For HRSN Connectors who are not HRSN Service Providers, delivery method may also include telephone.

(12) A request for HRSN Services that does not comply with the requirements of this rule is not considered complete and is not subject to the service authorization timeframes identified in OAR 410-120-2015 and OAR 410-120-2020. However, MCEs or the Authority must make a good faith effort to work with the Member or HRSN Connector, or both, as applicable to obtain the minimum required information necessary for an HRSN Request to be complete in accordance with this rule. Good faith effort means at minimum, the Member is informed that their HRSN Request is incomplete and is provided with the support they may need to complete the HRSN Request or, as applicable, informing the HRSN Connector of the specific, additional information required to be provided in order for the HRSN Request to be completed. MCEs and the Authority must, when contacting and communicating with a member, utilize the member’s preferred contact method.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632
DMAP 14-2026, temporary amend filed 04/28/2026, effective 05/01/2026 through 10/27/2026
DMAP 97-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 79-2025, temporary amend filed 10/24/2025, effective 11/01/2025 through 04/29/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 144-2024, temporary amend filed 12/29/2024, effective 01/01/2025 through 06/29/2025
DMAP 130-2024, adopt filed 10/24/2024, effective 11/01/2024

Or. Admin. R. 410-120-2015 Temporary rule language in effect until 10/27/2026. HRSN Eligibility Screening.

(1) The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering, determining eligibility, and delivering Health Related Social Needs (HRSN) Services when a Member initiates a request for HRSN Service. The Authority finds that:

(a) HRSN Services are foundational health promoting services that foster engagement in health care services as well as improve health outcomes; and

(b) HRSN Self-Attestation (“Self-Attestation”) allows a Member to provide a statement that the MCE or the Authority may rely upon to assess eligibility for HRSN Services when Members have not established or sustained engagement in health care services.

(2) After receipt of a complete HRSN Request, an MCE and, as applicable, the Authority, shall offer to screen the Member for whom the HRSN Request was made. If the Member consents to the screening, the MCE or, as applicable, the Authority shall conduct an HRSN Eligibility Screening in accordance with OAR 410-120-0000, the timeline described in OAR 410-120-2020, and this rule to determine whether to the requested HRSN Service must be authorized.

(3) If the HRSN Connector does not include all the information in the HRSN Request that is necessary for determining whether the Member is eligible to receive an HRSN Service, the MCE or, as applicable, the Authority, must make a good faith effort to obtain all the information or documentation (or both) necessary in order to conduct the HRSN Eligibility screening, which includes attempts to contact the Member or HRSN Connector in accordance with OAR 410-120-2010. The MCE or Authority may refer the Member to an HRSN Service Provider who can support the Member to gather the documentation necessary to complete the Member’s HRSN Request, or may work directly with the Member to obtain the necessary documentation or information (or both).

(a) If an MCE determines the individual is enrolled in OHP but is enrolled in a different MCE or is enrolled in FFS, the MCE shall forward the HRSN Request to, as applicable, the MCE in which the Member is enrolled or the Authority;

(b) If the Authority determines the individual is enrolled in OHP but is enrolled in an MCE, the Authority shall forward the HRSN Request to the MCE in which the Member is enrolled.

(4) All Self-Attestations submitted by a Member through an HRSN Request must include the following information identified below in this Subsection (a) of this Section (4) and must be accepted by MCEs and the Authority as set out below in this Section (4).

(a) Members who submit Self-Attestations for HRSN Services must include in their HRSN Self-Attestation, at minimum, the following statements:

(A) The condition that fulfills eligibility criteria for the requested HRSN Service; and

(B) The information they have provided is true.

(b) MCEs and the Authority may accept Self-Attestations that are made orally by a Member so long as the MCE or, as applicable, the Authority documents the oral Self-Attestation and the Member signs or otherwise acknowledges the documentation.

(c) MCEs and the Authority must not require a Self-Attestation to be submitted in a specific format so long as the Self-Attestation includes the required elements listed in subsection (a) of this Section (4).

(5) Except as set forth in section (6) of this rule, the MCE, or as applicable the Authority, must conduct an HRSN Eligibility Screening based on the statements made in the Self-Attestation as follows:

(a) If the Self-Attestation does not include all the information necessary to complete the HRSN Eligibility Screening, the MCE, or as applicable the Authority, shall use good faith efforts to obtain all information necessary to complete the HRSN Eligibility Screening.

(b) The MCE, or as applicable the Authority, must verify or attempt to verify the information included in a Member’s Self-Attestation with existing, supporting documentation as follows:

(A) Enrollment in OHP Plus in accordance with OAR 410-120-1210 and the Member’s OHP number must be verified;

(B) The following HRSN Covered Populations must be verified:

(i) Individuals Transitioning to Dual Medicaid and Medicare Status;

(ii) Individuals identified as Young Adults with Special Health Care Needs.

(C) HRSN Social Risk Factors for HRSN Nutrition-Related Supports must be verified by determining whether the Member qualifies as Low Food Security or Very Low Food Security as measured by the U.S. Household Food Security Survey Module: Six Item Short Form from the U.S. Department of Agriculture published in May 2024, available here: https://ers.usda.gov/sites/default/files/_laserfiche/DataFiles/50764/short2024.pdf?v=81104

(D) HRSN Clinical Risk Factors for the following HRSN services must be verified:

(i) Medically Tailored Meals;

(ii) Rent and Utility Financial Assistance, with the exception of Domestic Violence,

(E) Good faith efforts must be made to verify:

(i) HRSN Covered Populations not identified in (B) of this subsection (b);

(ii) Social Risk Factors not identified in (C) of this subsection (b); and

(iii) Clinical Risk Factors not identified in (D) of this subsection (b).

(c) All good faith efforts to verify information and collect documentation that could be used to verify a Member’s Self-Attestation must be documented by MCEs and, as applicable, the Authority.

(A) The absence of documentation is not alone a basis to conclude that the Self-Attestation it is not truthful.

(B) If the information included in the Member’s Self-Attestation that is identified in OAR 410-120-2015(5)(b)(E) cannot, using good faith efforts, be verified within a reasonable period of time the MCE, or as applicable the Authority, must make an eligibility determination as to whether, on its face, the information provided is likely truthful in light of the totality of the circumstances.

(6) HRSN Service requests that have been accepted and subject to screening based on Self-Attestation must be authorized or denied by MCEs or, as applicable the Authority, as follows:

(a) The requested or identified HRSN Services must be authorized if there is a reasonable basis to conclude that the Self-Attestation is likely truthful in light of the totality of the circumstances of the Member’s Self-Attestation and:

(A) The requested or identified HRSN Services are not duplicative of services the Member is already receiving; and

(B) In the case of HRSN Housing-Related Supports, all documentation required prior to authorization as identified in Table 5 of OAR 410-120-2005 have been obtained.

(b) The requested HRSN Service must be denied if:

(A) The identified HRSN Service request is for the HRSN Medically Tailored Meals Service within Nutrition-Related Supports and the Clinical Risk Factor cannot be verified by existing documentation to be medically necessary and appropriate by a registered dietician nutritionist licensed in the state of Oregon, or by a primary care physician or the Member’s physician specialist such as a cardiologist, oncologist or other similar physician specialist.

(B) The identified HRSN Service request is for HRSN Housing Related Supports, and all documentation that is identified as required in Table 5 of OAR 410-120-2005 has not been obtained.

(C) The identified HRSN Service request is duplicative of a service the member is receiving and there is no gap in service need.

(D) Good faith efforts reveal that the Self-Attestation is not likely truthful in light of the totality of the circumstances.

(7) In the event there is no documented evidence that verifies a self-attested health condition, it may be reasonable for MCEs or, as applicable, the Authority to deny an identified HRSN Service. In undertaking the good faith verification process and in making a determination about authorization or denial, MCEs or, as applicable, the Authority, must take into consideration that some conditions may be less likely to have existing, supporting documentation due to their nature, their symptoms, safety concerns, stigma, and barriers to care. In keeping with the forgoing considerations, MCEs and, as applicable, the Authority may deny an identified HRSN Service request based on self-attested clinical risk factors if:

(a) It would be objectively reasonable that the attested health condition would require some type of health care service because of the nature of the condition or its symptoms; and

(b) The member has been enrolled in the same CCO for a period of time that has been long enough that it would be reasonable to expect that at least some claims or medical records data for the self-attested health condition should have been submitted in MMIS that could have been reviewed.

(8) All MCEs and the Authority shall document the results of each HRSN Eligibility Screening, which must include at minimum, all of the following:

(a) Confirmation the individual is enrolled in the OHP Plus benefit package, including the Member’s OHP number;

(b) The HRSN Service requested, and whether the source of the HRSN Request was, Member self-referral, Member Representative, HRSN Connector (other than an HRSN Service Provider), HRSN Service Provider, or direct outreach from an MCE or the Authority;

(c) The HRSN Covered Population to which the Member belongs, based on existing documentation or Member Self-Attestation as applicable;

(d) The Member’s HRSN Clinical Risk Factor(s) applicable to the requested HRSN Service as set forth in the Tables 1 through 3 included in OAR 410-120-2005, based on existing documentation or Member Self-Attestation as applicable;

(e) The Member’s HRSN Social Risk Factors, as applicable to the requested HRSN Service as set forth in the tables included in OAR 410-120-2005, based on existing documentation or Member Self-Attestation as applicable;

(f) All other eligibility criteria that may be applicable to the requested HRSN Service as set forth in the tables included in OAR 410-120-2005;

(g) All required documentation that may be applicable to the requested HRSN Service as set forth in the tables included in OAR 410-120-2005;

(h) Confirmation or a determination that the Member is not receiving the same service as the requested HRSN Services from a local, state, or federally funded program, based on existing documentation or Member Self-Attestation. If the Member is receiving a similar service as the HRSN Service requested, the HRSN Service may be provided to an HRSN Authorized Member to fill gaps or otherwise supplement current program, but in no event shall a Member be authorized to receive duplicate existing services;

(i) Whether the Member’s HRSN Services are authorized (or denied).

(9) HRSN Eligibility Screenings must be completed within sufficient time to meet the deadline for authorizing or denying the HRSN Service within fourteen (14) days of receipt of the complete HRSN Request, with a possible extension of up to fourteen (14) additional days, in accordance with OAR 410-120-2020.

(10) If the individual requesting an HRSN Service is not enrolled in OHP or is enrolled in OHP but is not enrolled in OHP Plus, the MCE or the Authority shall connect individuals to resources to determine OHP Eligibility as requested or consented to by the Member.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632
DMAP 14-2026, temporary amend filed 04/28/2026, effective 05/01/2026 through 10/27/2026
DMAP 97-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 144-2024, temporary amend filed 12/29/2024, effective 01/01/2025 through 06/29/2025
DMAP 130-2024, adopt filed 10/24/2024, effective 11/01/2024

Or. Admin. R. 410-120-2020 Temporary rule language in effect until 10/27/2026. Authorization of HRSN Services; Referral to HRSN Service Provider.

(1) If, after completing the HRSN Eligibility Screening in accordance with OAR 410-120-2015, an MCE or, as applicable, the Authority, determines the Member meets all of the applicable HRSN Eligibility criteria, the MCE or the Authority shall authorize the identified HRSN Services and provide the Member notice as expeditiously as the circumstances require in accordance with this rule, which must not exceed fourteen (14) calendar days following the receipt of the complete HRSN Request, with a possible extension of up to fourteen (14) additional calendar days if:

(a) The Member, the Member’s representative, or provider requests an extension; or

(b) The MCE requests approval from the Authority, which must be accompanied by a substantiated need for additional information and an explanation of how the extension will be in the Member’s interest.

(2) The MCE or, as applicable, the Authority, must provide the Member with written notice of HRSN Rent and Utility Financial Assistance service authorization as expeditiously as the circumstances require following the receipt of the HRSN Request. In all cases, service authorization of HRSN Rent and Utility Financial Assistance must be made within fourteen (14) calendar days following the receipt of the complete HRSN Request; however, notice of service authorization for HRSN Rent and Utility Financial Assistance may be extended up to an additional fourteen (14) days following receipt of the HRSN Request so long as the extension complies with (1)(a) and (1)(b) of this rule OAR 410-120-2020.

(a) The written notice must comply with the Authority’s formatting and readability standards in OAR 410-141-3585 and 42 CFR § 438.10 and be written in plain language so a layperson can understand the notice.

(b) The written notice must include, at minimum, the following:

(A) Authorized Member’s legal name,

(B) Authorized Member’s Member ID and address,

(D) Date the Member’s HRSN Request was received,

(E) Date of notice of HRSN Service Authorization,

(F) Effective date of HRSN service authorization,

(G) Language Access Taglines as defined in OAR 410-141-3575, and

(H) MCE’s or, as applicable, the Authority’s contact information.

(c) If a Member was authorized for HRSN Rent and Utility Financial Assistance on or before September 1, 2025, then the MCE or, as applicable, the Authority, must send the Member a written notice of authorization if the Member:

(A) Was not provided with a written notice of that authorization; and

(B) Requests a written notice.

(C) Notices of HRSN Service Authorization sent to Members under this subsection (c), must comply with subsections (a) – (b) above and be sent as expeditiously as the Member’s circumstances require, but in all cases no later than seven (7) calendar days after the Member makes the request for written notice of HRSN Service Authorization.

(3) If, after completing the HRSN Eligibility Screening in accordance with OAR 410-120-2015, the MCE or, as applicable, the Authority, determines the Member does not meet all of the applicable HRSN Eligibility criteria, the MCE or Authority shall deny the request HRSN Service and provide the Member notice as expeditiously as the circumstances require in accordance with this rule OAR 410-120-2020 and OAR 410-141-3835(12)(e), which must not exceed fourteen (14) calendar days (with a possible extension so long as the extension complies with (1)(a) and (1)(b) of this rule OAR 410-120-2020) following the receipt of the complete HRSN Request. Contractor shall document the reason for the denial.

(4) In addition to the requirements set forth in section (1)(a)-(c) of this rule, all notices of HRSN Service Authorization must identify service duration, as is Clinically Appropriate. The duration of an Authorized HRSN Service shall not exceed the allowable service duration identified in the tables that are part of OAR 410-120-2005. The duration must be less than the maximum allowable service duration if and as required by the applicable tables in OAR 410-120-2005. The amount and scope of the Authorized HRSN Service must also be identified in all notices as required by and in accordance with 42 CFR 438.210.

(5) MCEs and the Authority must use reasonable efforts to ensure that HRSN Eligible Members who are receiving a similar service from a state, local, or federally funded organization or agency are only Authorized for any similar HRSN Services in accordance with OAR 410-120-2015.

(6) MCEs and the Authority must require clinical staff to review HRSN Service denials or reductions in scope, amount, or duration requested only when the following clinically-based eligibility circumstances exist:

(a) Specific to HRSN Home Changes for Health: A decision by an MCE or the Authority to deny a Member’s request for a Home Changes for Health device based on a determination that the Member does not meet the HRSN Home Changes for Health Device Social Risk Factor must include review by clinical staff to ensure the device was not Clinically Appropriate as a component of health services treatment or prevention as set forth in Table 1 included in OAR 410-120-2005.

(b) Specific to HRSN Home Changes for Safety: A decision by an MCE or the Authority to deny a Member’s request for a Home Changes for Safety service or reduce the scope, amount or duration of the service requested by the Member that is based on a determination that the Member does not meet the Home Changes for Safety service Social Risk Factors of the need to treat, improve, stabilize, or prevent their HRSN Clinical Risk Factor, must include a review by clinical staff to ensure the denial or limitation was Clinically Appropriate as set forth in OAR 410-120-0000.

(c) For all types of HRSN Services: Any decision by an MCE or the Authority to deny or reduce a Member’s request for an HRSN Service based on a determination that the Member did not have the HRSN Clinical Risk Factor applicable to the HRSN Service for which they were screened, must include review by clinical staff to ensure such determination was made in accordance with applicable clinical standards.

(d) Clinicians who review decisions to deny or reduce the scope, amount or duration of an HRSN Service must have appropriate expertise in addressing the Member’s HRSN needs.

(7) All MCEs and the Authority must document the approval, or denial, or reduction of HRSN Services.

(8) HRSN Services must be authorized before the expiration of HRSN Covered Populations eligible timeframes:

(a) For Adults and Youths Discharged from an HRSN Eligible Behavioral Health Facility and Adults and Youth Released from Incarceration, services must be authorized prior to the 366th day post-discharge.

(b) For Individuals Transitioning to Dual Eligible Status, services must be authorized within 90 days prior to the date Medicare coverage takes effect or prior to the 271st day after Medicare coverage takes effect.

(9) In accordance with 42 CFR 438.210, all MCEs must:

(a) Make available to their Members the same HRSN Services, in type, amount, duration and scope that the Authority offers to Fee-for-Service Members; and

(b) Screen and Authorize of HRSN Services for their HRSN Eligible Members in a manner that is no less restrictive than the Authority Screens and Authorizes HRSN Services for HRSN Eligible Fee-for-Service Members.

(10) All MCEs or, as applicable, the Authority, must notify HRSN Service Providers of an individual’s HRSN Service authorization or denial if the HRSN Service Provider submitted the HRSN Request for the individual and:

(a) May be or may have been the HRSN Service Provider that would have provided the requested HRSN Service; or

(b) Provided HRSN O&E Services to the individual who was authorized or denied the HRSN Service.

(11) Members who have been screened and authorized to receive and have received HRSN Services, must not be rescreened for the same HRSN Services they have received, except as set out in OAR 410-120-2005 and as set forth below in this section (11). Members may be rescreened for a HRSN Housing-Related and Nutrition-Related Support Service authorization when:

(a) The Member was screened but not authorized for the HRSN Service and their circumstances have since changed;

(b) The Member was screened and authorized for the HRSN Service, but they never received the authorized HRSN Service.

(12) In the event a Member is disenrolled from their MCE and enrolled in a new MCE or with the Authority, and the Member has been screened and authorized for, but not yet received, an HRSN Service, or was receiving HRSN services at the time of their disenrollment, and wishes to receive or continue to receive the authorized service, the new MCE, or as applicable, the Authority, must accept HRSN Eligibility Screening information used and provided by the predecessor MCE to conduct their own review as expeditiously as the Member’s circumstances require. In no event, however, shall the time for review exceed seven (7) calendar days following the receipt of the predecessor MCE’s information.

(a) If it is determined by the new MCE or as applicable, the Authority, that the Member is still eligible for the HRSN service and wishes to receive it, the new MCE or as applicable, the Authority, must authorize and provide the HRSN service as expeditiously as the Member’s circumstances require, in accordance with this rule OAR 410-120-2020.

(b) If it is determined by the new MCE or as applicable, the Authority, that the Member is no longer eligible for the HRSN service, the new MCE or as applicable, the Authority, must deny the HRSN service in accordance with this rule OAR 410-120-2020.

(13) In situations described in (12) of this rule, to ensure continuity of care, the predecessor MCE or as applicable, the Authority, must provide the new MCE, or as applicable, the Authority, with the HRSN Eligibility Screening information used to support the HRSN service authorization and provision of HRSN service for the now-former Member. This information must be provided to the new MCE, or as applicable, the Authority, as expeditiously as the Member’s circumstances require, and no later than seven (7) calendar days following the Member’s disenrollment and receipt of the new MCE’s or Authority’s request for HRSN Eligibility Screening information.

(14) In situations described in (12) of this rule, the new MCE or as applicable, the Authority, must avoid conducting unnecessary and redundant HRSN Eligibility Screenings and making requests to Members for documentation, if the predecessor MCE or the Authority is able to provide sufficient documentation to support the authorization and service provision of the HRSN service by the new MCE, or as applicable, the Authority.

(15) HRSN Authorized Members must be referred to an HRSN Service Provider that provides the HRSN Service that has been authorized. The referral must be made through a Closed Loop Referral unless the MCE or Authority is providing the HRSN Service in accordance with OAR 410-120-2000 (7)(a).

(a) The MCE or the Authority must inform the HRSN-Authorized Member they have the right to opt out of technology, like CIE, for Closed Loop Referrals and still receive HRSN Services;

(b) Before an HRSN-Authorized Member is referred to the applicable HRSN Service Provider, the MCE, or as applicable, the Authority, must, if the HRSN Service Provider is not already a Medicaid covered entity, obtain prior written authorization from the HRSN Authorized Member to share the information necessary to make the referral. The prior written authorization must comply with all applicable state and federal laws, which may include without limitation, HIPAA regulations such as 45 CFR 164.508;

(c) The provision of HRSN Services must not require an HRSN-Authorized Member to authorize the sharing of their personal information with the HRSN Service Provider;

(d) If the HRSN Authorized Member declines to authorize the sharing of their personal information in writing with an HRSN Service Provider, then the MCE or the Authority must provide the HRSN Authorized Member with a written referral that they may deliver to the HRSN Service Provider to which they have been referred.

(16) When referring HRSN-Authorized Members to HRSN Service Providers, MCEs and the Authority must:

(a) To the extent capacity permits, support the HRSN-Authorized Member’s choice of HRSN Service Provider;

(b) Identify and refer the HRSN Authorized Member to different HRSN Service Providers if the original provider is not able to provide the HRSN Service in a timely manner, and available in accordance with Care Coordination requirements outlined in OARs 410-141-3860, 410-141-3865, and 410-141-3870.

(17) MCEs or, as applicable, the Authority, must make a referral to an HRSN Service Provider that is capable of delivering the authorized HRSN Service(s) as expeditiously as a Member’s circumstances require. The timeframe for delivery of the HRSN Service must not exceed four (4) weeks, which is the same timeframe for scheduling appointments for Well Care as set forth in OAR 410-141-3515. The four (4) week timeframe starts at the point of service authorization. The HRSN Service(s) is considered “delivered” once the Member receives at least one unit of the HRSN Service that was authorized. Some service authorizations will continue beyond one month, but at minimum, the first unit must be delivered within four (4) weeks.

(18) In the event the HRSN Service Provider is not able to provide the authorized service within the required timeframe described in section (17) of this rule, the MCE may deliver the authorized HRSN Service provided conflicts of interest are guarded against as required and in keeping with OAR 410-120-2000(7)(a)-(c).

(19) The timeframe identified in section (17) of this rule is not required to be met in circumstances of impossibility related to:

(a) HRSN Service Vendor availability to deliver Home Changes for Health and Home Changes for Safety services, or

(b) Noncooperation of landlords or property managers, or

(c) Utility companies declining to accept payment for utility financial assistance, as determined by the Authority in its sole discretion, or

(d) Pantry Stocking and Fruit and Vegetable benefit card system limitations requiring the benefit to begin on a certain day of the month (e.g., first of the month). In these situations, the timeframe from service authorization to service delivery may exceed four (4) weeks to allow for a required start date, but in no circumstance shall the timeframe for service delivery exceed more than two calendar months.

(20) The timeframe identified in section (17) of this rule is not applicable to Members who are receiving HRSN Outreach and Engagement Services only. Instead, HRSN Outreach and Engagement Services must be delivered within a reasonable period of time in light of the Member’s availability.

(21) For Members who have not authorized the sharing of their information with an HRSN Service Provider, the four (4) week timeframe identified in section (17) of this rule shall commence when the HRSN-Authorized Member has delivered the referral to the referred HRSN Service Provider and the HRSN Service Provider has confirmed with the MCE or, as applicable, the Authority, receipt of the referral.

(22) If a Member is facing Imminent Eviction as defined in OAR 410-120-0000 when the Member first requests a HRSN Rent and Utility Financial Assistance, and the MCE or the Authority cannot provide the Member with rent service within the time frame necessary to keep the Member housed, MCEs and the Authority must, whenever possible, refer that Member to local or state providers or programs that may have the ability to address the Member’s Imminent Eviction. If the MCE or Authority cannot provide the requested rent service in the needed timeframe, the MCE or Authority may send a service denial.

(23) Even though the Authority and MCEs are not responsible for preventing Imminent Eviction in circumstances described in section (22), MCEs and the Authority must still screen Members in these situations for eligibility for other HRSN Services, including other HRSN Housing Supports, and if Authorized for the other HRSN Service, refer the HRSN Authorized Member to the applicable HRSN Service Provider(s).

History

Statutory/Other Authority: ORS 413.042 & SB 690 (2025)
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632
DMAP 14-2026, temporary amend filed 04/28/2026, effective 05/01/2026 through 10/27/2026
DMAP 97-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 62-2025, temporary amend filed 08/27/2025, effective 09/01/2025 through 02/27/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 130-2024, adopt filed 10/24/2024, effective 11/01/2024

Or. Admin. R. 410-120-2025 HRSN Person-Centered Service Plan (PCSP)

(1) Upon authorization of HRSN Services, the MCE or, as applicable, the Authority, shall, together with the HRSN Authorized Member, update their Care Plan as outlined in OAR 410-141-3870 to include an HRSN PCSP for the authorized HRSN Service(s).

(2) The HRSN PCSP shall be a written component of the Member’s Care Plan as outlined in OAR 410-141-3870 and developed with and agreed upon by the Member, the Member’s Representative, or both, as applicable.

(3) If the HRSN Authorized Member does not have a Care Plan in place in accordance with OAR 410-141-3870, the HRSN PCSP shall serve as their Care Plan and must be included in the Member’s Care Profile as outlined in OAR 410-141-3865.

(4) MCEs and the Authority shall ensure the HRSN PCSP is documented and includes all of the following elements:

(a) The Authorized HRSN Service(s);

(b) The Authorized HRSN Service duration;

(d) The HRSN Service Provider, as applicable, to which the Member is referred, which must reflect the Member choice, or a mutually agreeable option if choices are limited;

(e) The determination that the Authorized HRSN Service, unit(s) of service, and service duration are Clinically Appropriate based on HRSN Clinical and Social Risk Factors for the Authorized HRSN Service;

(f) The goals of the HRSN Service(s) for which the Member has been authorized, or provided (in the case of HRSN O&E), including the identification of other HRSN Services or other OHP or other benefit programs or services the Member may need (if not already included in the Member’s Care Plan).

(g) The follow-up and transition plan, including conducting rescreening for new HRSN Services or, in accordance with OAR 410-120-2020, previously approved but undelivered HRSN Services prior to the conclusion of the then-current Authorized HRSN Service; and

(h) The designated person or team within the MCE or the Authority that is responsible for managing the HRSN Authorized Member’s HRSN Services.

(5) The MCE or, as applicable, the Authority, is responsible for managing the HRSN Authorized Member’s HRSN Services and HRSN PCSP. The HRSN PCSP must, in accordance with OAR 410-141-3870, include relevant information from providers involved in the HRSN Authorized Member’s care.

(6) The MCE or, the Authority, as applicable must ensure and document the Member’s HRSN Service needs are being met and/or have been met by the HRSN Service Provider in compliance with the Member’s HRSN PCSP.

(7) When it is convenient for the HRSN Authorized Member, either before or after the HRSN Service delivery, depending upon the urgency of receipt of the HRSN Service, the MCE or, as applicable, the Authority, shall have no less than one meeting with the HRSN-Authorized Member, their Representative, or both, as applicable, either in person or by telephone or videoconference, during development of the HRSN PCSP, unless such Member declines participation.

(8) If efforts to have a meeting with the HRSN Authorized Member are unsuccessful, or if the HRSN Authorized Member expressly declines to participate in the development of the HRSN PCSP, the HRSN Authorized Member is still entitled to receive the HRSN Services for which they have been authorized. Neither the MCE nor the Authority has the right to deny the provision of HRSN Services due to the Member’s desire to not participate in the development of the HRSN PCSP. In all such circumstances, the MCE or the Authority must document:

(a) The efforts made to have one or more meetings with the Member, including identifying the specific attempts and barriers to having the meetings; and

(b) The Member’s reasons for not participating in the HRSN PCSP to the maximum extent feasible; and

(c) If the HRSN Authorized Member declines participation in the HRSN PCSP or attempts to schedule meetings are unsuccessful, the HRSN Eligibility Screening shall serve as justification for provision of HRSN Services and shall be documented to the Member’s Care Plan in lieu of an HRSN PCSP as required in OAR 410-141-3870.

(9) A Representative may receive an HRSN Service on behalf of a child who has been Authorized to receive an HRSN Service if it is developmentally appropriate, as determined through the development of the HRSN PCSP.

(10) For Members receiving the HRSN Pantry Stocking Benefit, the PCSP may serve as, and meet the requirement for, the Nutrition Care Plan as outlined in OAR 410-120-0000.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632
DMAP 97-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 130-2024, adopt filed 10/24/2024, effective 11/01/2024

Or. Admin. R. 410-120-2030 HRSN Service Provider Qualifications

(1) MCEs and the Authority shall ensure that all contracted HRSN Service Providers meet both the general qualifications described in (2)(a-j) below and the domain and service-specific qualifications described in (3) – (6) below necessary for providing the HRSN Services for which they have contracted.

(2) General HRSN Service Provider Qualifications: All contracted HRSN Service Providers must:

(a) Maintain an active business registration with the Oregon Secretary of State, except for governmental entities.

(b) Be accessible to Members, including having the operating hours and the staff necessary to meet the Members’ needs.

(c) Demonstrate their ability or experience to effectively serve at least one of the Authority’s Priority Populations (defined in ORS 413.256).

(d) Demonstrate they employ or contract with administrative and service delivery staff, who are, as reasonably determined by the MCE or the Authority qualified to perform and fulfill the responsibilities of their jobs.

(e) Demonstrate they provide professional, culturally and linguistically appropriate, responsive and trauma-informed services, which includes the ability to:

(A) Supply language interpretation and translation services to those Members who have limited English proficiency, and American Sign Language (ASL) services for to those Members who require ASL in order to communicate; and

(B) Respond to the cultural needs of the diverse populations they serve by performing services in accordance with National CLAS Standards.

(f) Provide documentation that demonstrates a history of responsible financial administration via recent annual financial reports, an externally conducted audit, or other similar documentation.

(g) Meet readiness standards defined by the Authority in this rule below. Compliance with readiness standards may be made by attestation or including in the HRSN Service Provider contracts their agreement and ability to comply with all of the following:

(A) Reporting and oversight requirements established by the Authority or the MCE or, as applicable, both;

(B) All laws relating to information privacy and security applicable to their business;

(D) All obligations related to participating in the Closed Loop Referral process (documented status of referrals and services ); and

(E) Invoicing for HRSN Services as agreed upon in their contract with the MCE and as applicable, the Authority, to provide HRSN Services.

(h) Be enrolled as a Medicaid HRSN Service Provider as required under OAR 410-120-1260.

(i) Not be delegated any responsibility for HRSN Service authorization or Service Planning.

(3) MCEs have the right to, but are not obligated to, require HRSN Service Providers to use technology (e.g., CIE) to conduct Closed Loop Referrals for HRSN Services. If an MCE chooses to require the use of CIE, MCEs must permit HRSN Service Providers to request an exception from the MCE based on inability to participate and available supports are insufficient.

(4) HRSN Housing Service Provider Qualifications: In addition to ensuring compliance with the requirements set out in section (2) of this rule, MCEs and, as applicable, the Authority shall ensure that HRSN Service Providers providing Housing-Related Supports meet the following domain and service-specific provider qualifications as set forth in the HRSN Housing Specific Provider Qualifications Table 1, which is included in this rule. All HRSN Housing Related Support Service Providers must:

(a) Have knowledge of principles, methods, and procedures of the HRSN Housing-Related Supports described in OAR 410-120-2005 in Table 4, or comparable services, that are relevant for the HRSN Services they have been contracted to provide.

(b) Be trained and credentialed, if applicable, to provide the specific HRSN Housing-Related Supports Service they have contracted to provide. MCEs and the Authority have the right, based on their reasonable discretion, to determine the appropriate level of training or licensure required for each HRSN Service Provider with which they contract.

(c) For HRSN Home Changes for Health Service Provider Qualifications, it is preferred that MCEs contract with HRSN Service Providers providing Home Changes for Health that are capable of both delivering and installing the devices described in OAR 410-120-2005 Table 4, Column (a). In the event an HRSN Service provider does not provide installation services, MCEs must ensure installation services are also performed by a different, qualified HRSN Service Provider or HRSN Service Vendor(s).

(5) HRSN Nutrition Service Provider Qualifications: In addition to ensuring compliance with the requirements set out in section (2) of this rule, MCEs and, as applicable, the Authority shall further ensure that HRSN Service Providers providing Nutrition-Related Supports meet the domain and service-specific provider qualifications identified in Table 2 included in this rule. All HRSN Nutrition Related Supports Service Providers must:

(a) Have knowledge of principles, methods and procedures of the HRSN Nutrition-Related Supports described in OAR 410-120-2005 in Table 6, or comparable services, that are relevant for the HRSN Services they have been contracted to provide, which includes meeting the HRSN Authorized Members’ nutritional needs.

(b) Comply with best practice guidelines, industry standards, and all applicable federal, state, and local laws governing food safety standards.

(c) Be trained and accredited, to the extent appropriate or required (or both) based on the applicable nutrition industry standard, to provide the specific service. MCEs and the Authority have the right, based on their reasonable discretion, to determine the appropriate level of training or licensure required for each contracted provider of a HRSN nutrition service, as long as they ensure providers are contractually required to act in accordance with nutrition-related national guidelines, such as the Dietary Guidelines for Americans, or evidence-based practice guidelines for specific chronic diseases and conditions. Depending on the specific service being provided, appropriate training and credentialing may entail:

(A) Relevant training(s) (e.g., webinar courses provided by SNAP-Ed, CDC-approved training for the National Diabetes Prevention Program Lifestyle Coach position, or other trainings from accredited nutrition organizations); or

(B) Certification (e.g., Certified Nutrition & Wellness Educator by the American Association of Family & Consumer Sciences); or

(d) Have the ability to meet the diverse needs of HRSN Authorized Member’s personal and cultural dietary preferences.

(e) Have the capacity to provide services on a one-time, daily, weekly, biweekly or monthly basis, depending on the specific service’s permitted frequency and Member’s preference.

(6) HRSN Outreach and Engagement Service Provider Qualifications. In addition to ensuring compliance with the requirements set out in section (2) of this rule, MCEs and, as applicable, the Authority, must further ensure that all HRSN Outreach and Engagement Service Providers meet the following domain specific qualifications:

(a) Have knowledge of principles, methods, and procedures of the HRSN Outreach and Engagement services, or comparable services for which they have contracted, which includes, connecting HRSN-Authorized Members to benefits and services other than HRSN Services.

(b) Have the capacity to carry out the responsibilities outlined in the HRSN Outreach and Engagement service descriptions in Table 7 in OAR 410-120-2005. MCEs and the Authority shall have the right, using their reasonable discretion, to determine whether an HRSN Service Provider has the skills, education, or experience to necessary for providing HRSN Outreach and Engagement Services.

(A) Cultural specificity and responsiveness approaches;

(B) Community outreach and engagement best practices;

(C) Basic eligibility and enrollment policies and practices for OHP, the HRSN program, and federal and state entitlements and benefits including SNAP, WIC, TANF, Social Security, Social Security Disability, and Veterans Affairs benefits, and federal and state housing programs;

(D) Local community resources for supporting basic needs such as access to shower, laundry, shelter, and food;

(E) Excellent oral communication skills with the ability to explain complex information to individuals—including those in the Authority’s HRSN Priority Populations — in an understandable, trauma-informed, and culturally responsive way; and

(F) Ability to maintain strict confidentiality and handle sensitive information appropriately.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632
DMAP 97-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 42-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 28-2025, temporary amend filed 02/12/2025, effective 02/14/2025 through 06/29/2025
DMAP 130-2024, adopt filed 10/24/2024, effective 11/01/2024

Or. Admin. R. 410-120-2035 Temporary rule language in effect until 12/31/2026. HRSN Rent and Utility Financial Assistance Benefit Transfer

(1) HRSN Rent and Utility Financial Assistance Benefit Transfer is the process by which a Member may temporarily pause or transfer, or both pause and transfer, their current, authorized HRSN Rent and Utility Financial Assistance benefit to a new address after service delivery has begun. This rule is effective while Executive Order No. 26-10 is active. A Member must meet the qualifications for HRSN Rent and Utility Financial Assistance Benefit Transfer described in (2).

(2) Under the requirements set out in OAR 410-120-2005, the HRSN Rent and Utility Financial Assistance cannot be transferred to another address once the provider has made the first payment and the Member has received any part of the benefit. Also, recurring payments of HRSN Rent and Utility Financial Assistance must be provided over a period of consecutive months. The exception to the aforementioned requirements in OAR 410-120-2005, as described in this rule, include a situation where the Member qualifies for the HRSN Rent and Utility Financial Assistance Transfer. Members may qualify for an HRSN Rent and Utility Financial Assistance Transfer if all of the following conditions are met:

(a) The Member has been authorized for HRSN Rent and Utility Financial Assistance and has received at least one month of the benefit;

(b) The Member is experiencing displacement due to one or more of the wildfires that occurred during the period Executive Order No 26-10 was in effect;

(c) The Landlord or Property Manager and the Member have completed, signed, and submitted the HRSN Notice of Impact Form to the CCO or the Authority, as applicable. The HRSN Notice of Impact Form states that the residence for which the Member was receiving the HRSN Rent and Utility Financial Assistance has become unsafe or unhealthy to reside as a direct result of the wildfire;

(d) The Member is still eligible for the service, as described in OAR 410-120-2005, at the time the HRSN Rent and Utility Financial Assistance will be transferred or resumed; and

(e) There is at least one month remaining of the authorized HRSN Rent and Utility Financial Assistance that can be provided before the 1115 Waiver period expires on September 30, 2027.

(3) In the event a Member pauses their HRSN Rent and Utility Financial Assistance due to the situation described in (2) of this rule while they attempt to secure different housing, the Member may receive or continue to receive HRSN Tenancy Supports and HRSN Storage Fee Assistance if the Member is eligible for and has been authorized to receive those services. In no circumstance may the benefit duration for HRSN Tenancy Supports or HRSN Storage Fee assistance exceed the allowable timeframes described in OAR 410-120-2005.

(4) The CCO or the Authority must approve or deny the request for HRSN Rent and Utility Financial Assistance Transfer as expeditiously as the Member’s circumstances require, but in no event later than seven (7) days after the date the Member submits to the CCO or, as applicable, the Authority, the HRSN Notice of Impact Form.

(5) If a denial of the HRSN Rent and Utility Financial Assistance Transfer leads to a reduction in services from the original, authorized HRSN Rent and Utility Financial Assistance, the CCO, or as applicable, the Authority, must send the Member a notice of adverse benefit determination in accordance with OAR 410-141-3835.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665 & 414.719
DMAP 34-2026, temporary adopt filed 08/12/2026, effective 08/15/2026 through 12/31/2026

Division 121 PHARMACEUTICAL SERVICES

Or. Admin. R. 410-121-0000 Foreword and Definition of Terms

(1) The Health Systems Division (Division) Oregon Administrative Rules (OAR) are designed to assist providers in preparing claims for services provided to the Division’s fee-for-service clients. Providers must use Pharmaceutical OARs in conjunction with the General Rules OARs (chapter 410, division 120) for Oregon Medical Assistance Programs.

(2) Pharmaceutical services delivered through a managed care plan or a Coordinated Care Organization (CCO) contracted with the Division under the Oregon Health Plan (OHP) are subject to the policies and procedures established in the OHP administrative rules (chapter 410, division 141) and by the specific managed care plan or CCO.

(3) Definition of Terms:

(a) “Actively Practicing” means the active practice of medicine as described in ORS chapter 689 or the active practice of pharmacy as described in ORS chapter 677.

(b) “Authority” means the Oregon Health Authority. See the Oregon Health Authority definition in General Rules (chapter 410, division 120);

(c) “Average Manufacturer’s Price (AMP)” means the average price that manufacturers sell medication to wholesalers and retail pharmacies, as further clarified in 42 CFR 447;

(d) “Bulk Dispensing” means multiple doses of medication packaged in one container labeled as required by pertinent federal and state laws and rules;

(e) “Centers for Medicare and Medicaid Services (CMS) Basic Rebate” means the quarterly payment by the manufacturer of a drug pursuant to the manufacturer’s CMS Medicaid Drug Rebate Agreement made in accordance with Section 1927(c) of the Social Security Act (42 U.S.C. 1396r-8(c)). See 410-121-0157;

(f) “CMS Consumer Price Index (CPI) Rebate” means the quarterly payment by the manufacturer pursuant to the manufacturer’s CMS Medicaid Drug Rebate Agreement made in accordance with Section 1927(c)(2) of the Social Security Act (42 U.S.C. 1396r-8(c));

(g) “Compendia” means those resources widely accepted by the medical profession in the efficacious use of drugs, including the following sources:

(A) The American Hospital Formulary Service Drug information;

(B) The United States Pharmacopeia Drug Information (or its successor publications);

(D) Peer-reviewed medical literature;

(E) Drug therapy information provided by manufacturers of drug products consistent with the federal Food and Drug Administration requirements.

(h) “Community Based Care Living Facility” means for the purposes of the Division’s Pharmacy Program, a home, facility, or supervised living environment licensed or certified by the State of Oregon that provides 24-hour care, supervision, and assistance with medication administration. These include but are not limited to:

(A) Supportive living facilities;

(B) Twenty-four hour residential services;

(D) Semi-independent living programs;

(E) Assisted living and residential care facilities;

(F) Group homes and other residential services for people with developmental disabilities or needing mental health treatment; and

(G) Inpatient hospice.

(i) “Compounded Prescription” means the following:

(A) A prescription that is prepared at the time of dispensing and involves the weighting of at least one solid ingredient that must be a reimbursable item or a legend drug in a therapeutic amount;

(B) Compounded prescription further defined to include the Oregon Board of Pharmacy definition of compounding (see OAR 855-006-0005).

(j) “Dispensing” means issuance of a prescribed quantity of an individual drug entity by a licensed pharmacist;

(k) “Director” means the director of the Authority;

(L) “Drug Order/Prescription” means the following:

(A) A medical practitioner's written or verbal instructions for a patient's medications; or

(B) A medical practitioner's written order on a medical chart for a client in a nursing facility.

(m) “Durable Medical Equipment and Supplies (DME)” means equipment and supplies as defined in OAR 410-122-0010, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies;

(n) “Intermediate Care Facility” means a facility providing regular health-related care and services to individuals at a level above room and board, but less than hospital or skilled nursing levels as defined in ORS 442.015;

(o) “Legend Drug” means a drug limited by Section 503(b)(1) of the Federal Food, Drug, and Cosmetic Act to being dispensed by or upon a medical practitioner’s prescription because the drug is:

(A) Habit-forming;

(B) Toxic or having potential for harm; or

(i) The product label of a legend drug is required to contain the statement: “CAUTION: FEDERAL LAW PROHIBITS DISPENSING WITHOUT A PRESCRIPTION;”

(ii) A legend drug includes prescription drugs subject to the requirement of Section 503(b)(1) of the federal Food, Drug, and Cosmetic Act that shall be exempt from Section 502(F)(1) if certain specified conditions are met.

(p) “Long Term Care Facility” means skilled nursing facilities and intermediate care facilities with the exclusions found in ORS 443.400 to 443.455;

(q) “Maintenance Medication” means drugs that have a common indication for treatment of a chronic disease, and the therapeutic duration is expected to exceed one year. This is determined by a First DataBank drug code maintenance indicator of “Y” or “1;”

(r) “Mental Health Drug” means a type of legend drug defined by the Oregon Health Authority (Authority) by rule that includes but is not limited to those drugs classified by First DataBank in the following Standard Therapeutic Classes:

(A) Therapeutic Class 7 ataractics-tranquilizers and Therapeutic Class 11 psychostimulants-antidepressants;

(B) Depakote, Lamictal, and their generic equivalents and other drugs that the Division specifically carved out from capitation from CCOs as specified in OAR 410-141-3855.

(s) “Narrow Therapeutic Index (NTI) Drug” means a drug that has a narrow range in blood concentrations between efficacy and toxicity and requires therapeutic drug concentration or pharmacodynamic monitoring;

(t) “National Average Drug Acquisition Cost (NADAC)” means the rate that is established by CMS or its contractor by rolling surveys of pharmacies nationwide to verify the actual invoice amount paid by the pharmacy or corporate entity to wholesalers, manufacturers, or distribution centers for the product. The NADAC is the average of invoice amounts for individual drug products based on the Generic Sequence Number (GSN);

(u) “Net Price” means the amount a drug costs the Division and is calculated using the following formula: OR-AAAC, minus CMS Basic Rebate, minus CMS CPI Rebate, minus State Supplemental Rebate;

(v) “Nominal Price” means sales at less than 10 percent of the Average Manufacturer’s Price (AMP);

(w) “Non-Preferred Products” means any medication in a class that has been evaluated and that is not listed on the Practitioner-Managed Prescription Drug Plan Preferred Drug List in OAR 410-121-0030;

(x) “Nursing Facility” means an establishment that is licensed and certified by the Department’s Aging and People with Disabilities Division (APD) as a Nursing Facility;

(y) “Oregon Average Actual Acquisition Cost (OR-AAAC)” means the rate that is established by the Division or its contractor by rolling surveys of enrolled pharmacies to verify the actual invoice amount paid by the pharmacy or corporate entity to wholesalers, manufacturers, or distribution centers for the product. The AAAC is the average of invoice amounts for individual drug products based on the Generic Sequence Number (GSN);

(z) “Pharmacist” means an individual who is licensed as a pharmacist under ORS chapter 689;

(aa) “Physical Health Drug” means all other drugs not included in the definition of a “mental health drug” according to this rule;

(bb) “Point-of-Sale (POS)” means a computerized, claims submission process for retail pharmacies that provides on-line, real-time claims adjudication;

(cc) “Preferred Drug List (PDL)” means the list of prescription drugs in selected classes that the Authority in consultation with the Pharmacy & Therapeutics Committee (P & T) has determined represent the most effective drugs available at the best possible price. (See details for the Division’s PMPDP PDL in OAR 410-121-0030.) The following are two types of preferred drug lists:

(A) “Enforceable Physical Health Preferred Drug List” means the list of “preferred” drug products used to treat physical health conditions. The “preferred” drugs may nevertheless require prior authorization (PA) for clinical reasons. Drugs prescribed that do not appear on the PDL (non-preferred products) shall be subject to PA;

(B) “Voluntary Mental Health Preferred Drug List” means the list of “preferred” drug products used to treat mental health conditions. Any drug prescribed for the treatment of mental health diagnosis shall be exempt from non-clinical PA requirements by the Division.

(dd) “Preferred Products” means products in classes that have been evaluated and placed on the Practitioner Managed Prescription Drug Plan (PMPDP) PDL in OAR 410-121-0030;

(ee) “Prescriber” means any person authorized by law to prescribe drugs;

(ff) “Prescription Splitting” means any one or a combination of the following actions:

(A) Reducing the quantity of a drug prescribed by a licensed practitioner for prescriptions not greater than 34 days, except as needed for Prescription Synchronization (see OAR 410-121-0146);

(B) Billing the agency for more than one dispensing fee when the prescription calls for one dispensing fee for the quantity billed, except as needed for Prescription Synchronization (see OAR 410-121-0146);

(C) Separating the ingredients of a prescribed drug and billing the agency for separate individual ingredients, with the exception of compounded medications (see OAR 410-121-0146); or

(D) Using multiple 30-day cards to dispense a prescription when a lesser number of cards will suffice.

(gg) “Prescription Synchronization” means the process of, at the client’s direction, aligning the refill dates of a client’s prescription drugs so drugs that are refilled at the same frequency may be refilled concurrently;

(hh) “Prior Authorization Program (PA)” means the prior authorization program is a system of determining, through a series of therapeutic and clinical protocols, which drugs require authorizations prior to dispensing:

(A) OAR 410-121-0040 lists the drugs or categories of drugs requiring PA;

(B) The practitioner or practitioner's licensed medical personnel listed in OAR 410-121-0060 may request a PA.

(ii) “State Supplemental Rebates” means the Division and CMS approved discounts paid by manufacturers per unit of drug. These rebates are authorized by the Social Security Act section 42 USC 1396r-8(a)(1) and are in addition to federal rebates mandated by the Omnibus Budget Rehabilitation Act (OBRA 90) and the federal rebate program;

(jj) “Unit Dose” means a sealed, single unit container of medication so designed that the contents are administered to the patient as a single dose, direct from the container, and dispensed following the rules for the unit dose dispensing system established by the Oregon Board of Pharmacy;

(kk) “Urgent Medical Condition” means a medical condition that arises suddenly, is not life-threatening, and requires prompt treatment to avoid the development of more serious medical problems;

(LL) “Usual and Customary Price” means a pharmacy's charge to the general public that reflects all advertised savings, discounts, special promotions, or other programs including membership based discounts initiated to reduce prices for product costs available to the general public, a special population, or an inclusive category of customers;

(mm) “Wholesale Acquisition Cost (WAC)” means the price paid by a wholesaler for drugs purchased from the wholesaler's supplier, typically the manufacturer of the drug. WAC is the price of a covered product by the National Drug Code (NDC) as published by First DataBank, MediSpan, or Red Book;

(nn) “340B Pharmacy” means a federally designated community health center or other federally qualified covered entity that is listed on the Health Resources and Services Administration (HRSA) website.

NOTE: Publications referenced are available from the agency.

History

Statutory/Other Authority: ORS 413.042, 414.065 & 414.325
Statutes/Other Implemented: ORS 414.065
DMAP 71-2025, amend filed 09/25/2025, effective 10/01/2025
DMAP 11-2018, amend filed 03/02/2018, effective 03/02/2018
DMAP 76-2015, f. 12-22-15, cert. ef. 1-1-16
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 27-2011(Temp), f. & cert. ef. 9-30-11 thru 3-15-12
DMAP 23-2011, f. 8-24-11, cert. ef. 9-1-11
DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 14-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 18-2004, f. 3-15-04, cert. ef. 4-1-04
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-121-0021 Organizations Authorized to Provide Pharmaceutical Prescription Services

(1) Pharmacies, and Medicare certified independent rural health clinics providing urgent medical services for clients as defined in ORS 414.325(7) may provide drug prescription services for fee-for-service Division of Medical Assistance Programs (Division) clients and receive reimbursement from Division by complying with all the following requirements:

(a) Comply with all applicable Federal and State statutes, regulations and rules;

(b) Meet all current licensing and regulatory requirements;

(d) Pharmacies must have a current National Association of the Board of Pharmacy (NABP) number to bill Division;

(e) Medicare certified independent rural health clinics must have a pharmacist, physician, or nurse practitioner, licensed to dispense and bill drug prescriptions; and

(f) Comply with Division pharmacy billing requirements.

(2) Refer to OAR 410-120-1260 for enrollment details.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 9-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 41-2004, f. 6-24-04 cert. ef. 7-1-04
OMAP 84-2003, f. 11-25-03 cert. ef. 12-1-03

Or. Admin. R. 410-121-0030 Practitioner-Managed Prescription Drug Plan

(1) The Practitioner-Managed Prescription Drug Plan (PMPDP) is a plan that ensures that OHP fee-for-service clients have access to the most effective prescription drugs appropriate for their clinical conditions at the best possible price:

(a) Licensed health care practitioners, who are informed by the latest peer reviewed research, make decisions concerning the clinical effectiveness of the prescription drugs;

(b) Licensed health care practitioners also consider the client’s health condition, personal characteristics, and the client’s gender, race, or ethnicity;

(c) The PDL includes over-the-counter (OTC) products determined to be cost-effective and clinically appropriate by the Oregon Pharmacy and Therapeutics (P&T) Committee. Select OTC product classes are included as a covered pharmacy benefit for Oregon FFS members.

(2) PMPDP Preferred Drug List (PDL):

(a) The PDL is the primary tool the Division uses to inform licensed health care practitioners about the results of the latest peer-reviewed research and cost effectiveness of prescription drugs;

(b) The PDL contains a list of prescription drugs that the Division, in consultation with the Drug Use Review (DUR)/Pharmacy & Therapeutics Committee (P&T), has determined represent the most effective drugs available at the best possible price;

(c) The PDL shall include drugs that are Medicaid reimbursable and the Food and Drug Administration (FDA) has determined to be safe and effective.

(3) PMPDP PDL Selection Process:

(a) The Division shall utilize the recommendations made by the P&T that result from an evidence-based evaluation process as the basis for selecting the most effective drugs;

(b) The Division shall ensure the drugs selected in section (3)(a) of this rule are the most effective drugs available for the best possible price and shall consider any input from the P&T about other FDA-approved drugs in the same class that are available for a lesser relative price. The Division shall determine relative price using the methodology described in section (4) of this rule;

(A) The Division may evaluate more frequently if new safety information, or the release of new drugs in a class, or other information makes an evaluation advisable;

(B) New drugs in classes already evaluated for the PDL shall be non-preferred until the new drug has been reviewed by the P&T;

(C) The Division shall make all revisions to the PDL using the rulemaking process and shall publish the changes on the Division’s Pharmaceutical Services provider rules website.

(4) Relative cost and best possible price determination:

(a) The Division shall determine the relative cost of all drugs in each selected class that are Medicaid reimbursable and that the FDA has determined to be safe and effective;

(b) The Division may also consider dosing issues, patterns of use, and compliance issues. The Division shall weigh these factors with any advice provided by the P&T in reaching a final decision.

(5) Pharmacy providers shall dispense prescriptions in the generic form unless:

(a) The practitioner requests otherwise pursuant to OAR 410-121-0155;

(b) The Division notifies the pharmacy that the cost of the brand name particular drug, after receiving discounted prices and rebates, is equal to or less than the cost of the generic version of the drug.

(6) The exception process for obtaining non-preferred physical health drugs that are not on the PDL drugs shall be as follows:

(a) If the prescribing practitioner in their professional judgment wishes to prescribe a physical health drug not on the PDL, they may request an exception subject to the requirements of OAR 410-121-0040;

(b) The prescribing practitioner must request an exception for physical health drugs not listed in the PDL subject to the requirements of OAR 410-121-0060;

(A) The prescriber in their professional judgment determines the non-preferred drug is medically appropriate after consulting with the Division or the Oregon Pharmacy Call Center; or

(B) Where the prescriber requests an exception subject to the requirement of section (6)(b) of this rule and fails to receive a report of PA status within 24 hours, subject to OAR 410-121-0060.

(7) Table 121-0030-1, PMPDP PDL dated July 1, 2026, is adopted and incorporated by reference and is found at: www.orpdl.org.

(8) Table 121-0030-2, PMPDP OTC dated January 1, 2025, is adopted and incorporated by reference and is found at: www.orpdl.org.

History

Statutory/Other Authority: ORS 413.032, 413.042, 414.065, 414.312, 414.316, 414.325 & 414.330 - 414.414
Statutes/Other Implemented: ORS 414.065, 414.325, 414.334, 414.353, 414.354, 414.361, 414.369 & 414.371
DMAP 27-2026, amend filed 06/29/2026, effective 07/01/2026
DMAP 12-2026, amend filed 03/27/2026, effective 04/01/2026
DMAP 89-2025, amend filed 12/15/2025, effective 01/01/2026
DMAP 75-2025, amend filed 09/30/2025, effective 10/01/2025
DMAP 52-2025, amend filed 06/25/2025, effective 07/01/2025
DMAP 37-2025, amend filed 03/31/2025, effective 04/01/2025
DMAP 153-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 125-2024, temporary amend filed 09/30/2024, effective 10/01/2024 through 03/29/2025
DMAP 109-2024, amend filed 07/01/2024, effective 07/01/2024
DMAP 84-2024, amend filed 04/04/2024, effective 04/04/2024
DMAP 96-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 78-2023, amend filed 09/23/2023, effective 10/01/2023
DMAP 54-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 10-2023, amend filed 03/28/2023, effective 04/01/2023
DMAP 95-2022, temporary amend filed 12/27/2022, effective 01/01/2023 through 06/24/2023
DMAP 87-2022, amend filed 12/13/2022, effective 12/20/2022
DMAP 75-2022, temporary amend filed 09/29/2022, effective 10/01/2022 through 12/27/2022
DMAP 64-2022, temporary amend filed 06/29/2022, effective 07/01/2022 through 12/27/2022
DMAP 61-2022, amend filed 06/26/2022, effective 06/27/2022
DMAP 45-2022, temporary amend filed 04/01/2022, effective 04/01/2022 through 06/25/2022
DMAP 54-2021, temporary amend filed 12/29/2021, effective 01/01/2022 through 06/25/2022
DMAP 53-2021, amend filed 12/28/2021, effective 12/28/2021
DMAP 43-2021, temporary amend filed 09/27/2021, effective 10/01/2021 through 12/27/2021
DMAP 29-2021, temporary amend filed 06/29/2021, effective 07/01/2021 through 12/27/2021
DMAP 26-2021, amend filed 06/24/2021, effective 06/29/2021
DMAP 14-2021, temporary amend filed 03/30/2021, effective 04/01/2021 through 06/29/2021
DMAP 69-2020, temporary amend filed 12/28/2020, effective 01/01/2021 through 06/29/2021
DMAP 65-2020, amend filed 12/21/2020, effective 12/27/2020
DMAP 53-2020, temporary amend filed 09/28/2020, effective 10/01/2020 through 12/27/2020
DMAP 41-2020, temporary amend filed 08/25/2020, effective 09/01/2020 through 12/27/2020
DMAP 32-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 28-2020, amend filed 06/24/2020, effective 06/28/2020
DMAP 9-2020, temporary amend filed 03/16/2020, effective 04/01/2020 through 06/28/2020
DMAP 6-2020, temporary amend filed 02/25/2020, effective 03/01/2020 through 06/28/2020
DMAP 67-2019, temporary amend filed 12/27/2019, effective 01/01/2020 through 06/28/2020
DMAP 53-2019, amend filed 12/12/2019, effective 12/27/2019
DMAP 43-2019, temporary amend filed 10/24/2019, effective 11/01/2019 through 12/27/2019
DMAP 24-2019, temporary amend filed 06/25/2019, effective 07/01/2019 through 12/27/2019
DMAP 21-2019, amend filed 06/21/2019, effective 06/28/2019
DMAP 10-2019, temporary amend filed 04/24/2019, effective 05/15/2019 through 06/29/2019
DMAP 6-2019, temporary amend filed 03/19/2019, effective 04/01/2019 through 06/29/2019
DMAP 107-2018, temporary amend filed 12/20/2018, effective 01/01/2019 through 06/29/2019
DMAP 106-2018, amend filed 12/19/2018, effective 12/19/2018
DMAP 93-2018, temporary amend filed 10/16/2018, effective 10/16/2018 through 12/27/2018
DMAP 77-2018, temporary amend filed 06/27/2018, effective 07/01/2018 through 12/27/2018
DMAP 29-2018, amend filed 05/02/2018, effective 05/02/2018
DMAP 60-2017, temporary amend filed 12/27/2017, effective 01/01/2018 through 06/29/2018
DMAP 33-2017(Temp), f. 8-24-17, cert. ef. 9-1-17 thru 12-27-17
DMAP 51-2017, amend filed 12/05/2017, effective 12/05/2017
DMAP 27-2017(Temp), f. 6-30-17, cert. ef. 7-1-17 thru 12-27-17
DMAP 23-2017, f. & cert. ef. 6-29-17
DMAP 14-2017(Temp), f. 4-28-17, cert. ef. 5-1-17 thru 6-29-17
DMAP 80-2016(Temp), f. 12-30-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 69-2016, f. & cert. ef. 12-1-16
DMAP 57-2016(Temp), f. 9-30-16, cert. ef. 10-1-16 thru 3-29-17
DMAP 43-2016(Temp), f. & cert. ef. 7-1-16 thru 12-27-16
DMAP 27-2016, f. 6-24-16, cert. ef. 6-28-16
DMAP 18-2016(Temp), f. 4-28-16, cert. ef. 5-1-16 thru 6-28-16
DMAP 84-2015(Temp), f. 12-23-15, cert. ef. 1-1-16 thru 6-28-16
DMAP 79-2015, f. 12-22-15, cert. ef. 12-27-15
DMAP 66-2015(Temp), f. & cert. ef. 11-6-15 thru 12-27-15
DMAP 64-2015(Temp), f. & cert. ef. 11-3-15 thru 12-27-15
DMAP 57-2015(Temp), f. 9-30-15, cert. ef. 10-1-15 thru 12-27-15
DMAP 37-2015(Temp), f. & cert. ef. 7-1-15 thru 12-27-15
DMAP 35-2015, f. 6-25-15, cert. ef. 6-26-15
DMAP 26-2015(Temp), f. 4-17-15, cert. ef. 4-18-15 thru 6-26-15
DMAP 10-2015(Temp), f. & cert. ef. 3-3-15 thru 8-29-15
DMAP 88-2014(Temp), f. 12-31-14, cert. ef. 1-1-15 thru 6-29-15
DMAP 78-2014(Temp), f. & cert. ef. 12-12-14 thru 6-9-15
DMAP 77-2014, f. & cert. ef. 12-12-14
DMAP 64-2014(Temp), f. 10-24-14, cert. ef. 10-29-14 thru 12-30-14
DMAP 52-2014(Temp), f. & cert. ef. 9-16-14 thru 1-11-15
DMAP 47-2014(Temp), f. & cert. ef. 7-15-14 thru 1-11-15
DMAP 37-2014, f. & cert. ef. 6-30-14
DMAP 28-2014(Temp), f. & cert. ef. 5-2-14 thru 6-30-14
DMAP 15-2014(Temp), f. & cert. ef. 3-21-14 thru 9-17-14
DMAP 1-2014(Temp), f. & cert. ef. 1-10-14 thru 7-9-14
DMAP 76-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 43-2013, f. & cert. ef. 8-16-13
DMAP 23-2013(Temp), f. 4-30-13, cert. ef. 5-1-13 thru 8-19-13
DMAP 6-2013(Temp), f. & cert. ef. 2-21-13 thru 8-19-13
DMAP 61-2012, f. 12-27-12, cert. ef. 1-1-13
DMAP 44-2012(Temp), f. & cert. ef. 9-26-12 thru 1-18-13
DMAP 40-2012(Temp), f. & cert. ef. 8-20-12 thru 1-18-13
DMAP 33-2012(Temp), f. 7-18-12, cert. ef. 7-23-12 thru 1-18-13
DMAP 29-2012, f. & cert. ef. 6-21-12
DMAP 26-2012, f. & cert. ef. 5-14-12
DMAP 18-2012, f. 3-30-12, cert. ef. 4-9-12
DMAP 12-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 19-2011, f. 7-15-11, cert. ef. 7-17-11
DMAP 2-2011(Temp), f. & cert. ef. 3-1-11 thru 8-20-11
DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 4-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 48-2006, f. 12-28-06, cert. ef. 1-1-07
OMAP 32-2006, f. 8-31-06, cert. ef. 9-1-06
OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 58-2005, f. 10-27-05, cert. ef. 11-1-05
OMAP 32-2005, f. 6-21-05, cert. ef. 7-1-05
OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05
OMAP 89-2004, f. 11-24-04 cert. ef. 12-1-04
OMAP 81-2004, f. 10-29-04 cert. ef. 11-1-04
OMAP 45-2004, f. 7-22-04 cert. ef. 8-1-04
OMAP 34-2004, f. 5-26-04 cert. ef. 6-1-04
OMAP 29-2004, f. 4-23-04 cert. ef. 5-1-04
OMAP 9-2004, f. 2-27-04, cert. ef. 3-1-04
OMAP 82-2003, f. 10-31-03, cert. ef. 11-1-03
OMAP 70-2003(Temp), f. 9-15-03, cert. ef. 10-1-03 thru 3-15-04
OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 47-2003, f. & cert. ef. 7-1-03
OMAP 35-2003, f. & cert. ef. 5-1-03
OMAP 29-2003, f. 3-31-03 cert. ef. 4-1-03
OMAP 36-2002, f. 8-30-02, cert. ef. 9-1-02
OMAP 31-2002, f. & cert. ef. 8-1-02
OMAP 25-2002, f. 6-14-02 cert. ef. 7-1-02

Or. Admin. R. 410-121-0032 Supplemental Rebate Agreements

(1) The Division of Medical Assistance Programs (Division) has both a, Centers for Medicare and Medicaid Services (CMS) approved Supplemental Rebate Agreement and a (CMS) approved Value based Agreement. These templates and instructions are available on the Oregon Health Authority’s (Authority) web site at: www.oregon.gov/OHA/healthplan/pages/pharmacy-policy.aspx

(2) The Division negotiates Supplemental Rebate Agreements for specific drug products through the Sovereign States Drug Consortium (SSDC) multi-state pool and pharmaceutical manufacturers. Negotiations are confidential, and shall not be disclosed, except in connection with an agreement/contract or as may be required by law. Confidentiality is required of any third party involved in administration of the agreement/contract.

(3) Manufacturers may submit supplemental rebate offers or value base offers for consideration to include their drug(s) on the Practitioner’s-Managed Prescription Drug Plan (PMPDP) Preferred Drug List (PDL), OAR 410-121-0030 after gaining access to the SSDC secure web-based offer entry system.

(4) Manufacturers must abide by requirements of the SSDC.

(5) The Practitioner-Managed Prescription Drug List (PMPDP) also called the Preferred Drug List (PDL) consist of drugs after the Food and Drug Administration (FDA) has determined to be safe and effective and reimbursable as determined by the Centers for Medicaid and Medicare Services (CMS), and evaluated using an evidence-based review process by the Pharmacy & Therapeutics Committee (P&T) . If pharmaceutical manufacturers enter into supplemental rebate agreements with the SSDC, the Authority may include that drug on the PDL.

(6)Acceptance of the offer:

(a) The Division may accept an offer through the SSDC;

(b) The SSDC shall notify manufacturers of the status of their offer(s).

(c) Supplemental Agreements shall be executed after signed by all parties, approved by CMS if required, and added to the PMPDP Preferred Drug List by the Administrative rule process.

(d) The Division may contract for the functions of tracking utilization, invoicing, and dispute resolution for supplemental rebate products.

History

Statutory/Other Authority: ORS 414.065, ORS 413.042, ORS 409.025, 409.040 & 409.110
Statutes/Other Implemented: ORS 414.065
DMAP 96-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 40-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 35-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 14-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 97-2004, f. 12-30-04, cert. ef. 1-1-05

Or. Admin. R. 410-121-0033 Polypharmacy Profiling

(1) The Division of Medical Assistance Programs may impose prescription drug payment limitations on clients with more than 15 unique fee-for-service drug prescriptions in a six-month period.

(2) The Division will review the client’s drug therapy in coordination with the client's prescribing practitioner to evaluate for appropriate drug therapy.

(3) Appropriate drug therapy criteria will include, but is not limited to, the following:

(a) Overuse of selected drug classes;

(b) Under-use of generic drugs;

(d) Drug to disease interactions;

(e) Drug to drug interactions;

(f) Inappropriate drug dosage;

(g) Drug selection for age;

(h) Duration of treatment;

(i) Clinical abuse or misuse.

(4) The Division Medical Director in conjunction with the Drug Use Review/Pharmacy & Therapeutics Committee will make final determinations on imposed drug prescription payment limitations relating to this policy.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 61-2012, f. 12-27-12, cert. ef. 1-1-13
DMAP 42-2012(Temp), f. & cert. ef. 9-12-12 thru 3-10-13
DMAP 12-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12
DMAP 27-2011(Temp), f. & cert. ef. 9-30-11 thru 3-15-12
OMAP 1-2004, f. 1-23-04, cert. ef. 2-1-04

Or. Admin. R. 410-121-0040 Prior Authorization Required for Drugs and Products

(1) Prescribing practitioners shall obtain prior authorization (PA) for the drugs and categories of drugs requiring PA in this rule, using the procedures set forth in OAR 410-121-0060.

(2) Except as provided in section (3) of this rule, all drugs and categories of drugs including, but not limited to, those drugs and categories of drugs that require PA shall meet the following requirements for coverage:

(a) Each drug shall be prescribed for conditions funded by the Oregon Health Plan (OHP) in a manner consistent with the Health Evidence Review Commission (HERC) Prioritized List of Health Services (OAR 410-141-3820 through 410-141-3825). If the medication is for a non-covered diagnosis, the medication may not be covered unless there is a co-morbid condition for which coverage would be allowed. The use of the medication shall meet corresponding treatment guidelines and be included within the client’s benefit package of covered services and not otherwise excluded or limited;

(b) Each drug shall also meet other criteria applicable to the drug or category of drug in these pharmacy provider rules, including PA requirements imposed in this rule.

(3) The Division shall grant exceptions to section (2) of this rule when coverage is required through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in chapter 410 division 151.

(4) The Authority may require PA for individual drugs and categories of drugs to ensure that the drugs prescribed are indicated for conditions funded by OHP and consistent with the Prioritized List of Health Services and its corresponding treatment guidelines (see OAR 410-141-3820). The drugs and categories of drugs that the Authority requires PA for this purpose are found in the Oregon Medicaid Fee-for-Service Prior Authorization Approval Criteria (PA Criteria guide) July 1, 2026 adopted and incorporated by reference and found at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Pharmacy.aspx

(5) The Authority may require PA for individual drugs and categories of drugs to ensure medically appropriate use or to address potential client safety risk associated with the particular drug or category of drug, as recommended by the Pharmacy & Therapeutics Committee (P&T) and adopted by the Authority in this rule. The drugs and categories of drugs for which the Authority requires PA for this purpose are found in the Pharmacy PA Criteria Guide.

(6) New drugs shall be evaluated when added to the weekly upload of the First Databank drug file:

(a) If the new drug is in a class where current PA criteria apply, all associated PA criteria shall be required at the time of the drug file load;

(b) If the new drug is indicated for a condition below the funding line on the Prioritized List of Health Services, PA shall be required to ensure that the drug is prescribed for a condition funded by OHP;

(7) PA shall be obtained for brand name drugs that have two or more generically equivalent products available and that are not determined Narrow Therapeutic Index drugs by the DUR/P&T Committee:

(a) Immunosuppressant drugs used in connection with an organ transplant shall be evaluated for narrow therapeutic index within 180 days after United States patent expiration;

(b) Manufacturers of immunosuppressant drugs used in connection with an organ transplant shall notify the Authority of patent expiration within 30 days of patent expiration for section (5)(a) of this rule to apply;

(A) If criteria established in section (4) or (5) of this rule applies, follow that criteria;

(B) If section (7)(a) of this rule does not apply, the prescribing practitioner shall document that the use of the generically equivalent drug is medically contraindicated and provide evidence that either the drug has been used and has failed or that its use is contraindicated based on evidence-based peer reviewed literature that is appropriate to the client’s medical condition.

(8) PA shall be obtained for non-preferred Preferred Drug List (PDL) products in a class evaluated for the PDL except in the following cases:

(a) The drug is a mental health drug as defined in OAR 410-121-0000;

(b) The original prescription is written prior to 1/1/10;

(d) The prescription is a refill of an immunosuppressant.

(9) PA may not be required:

(a) When the prescription ingredient cost plus the dispensing fee is less than the PA processing fees as determined by the Authority;

(b) For over-the-counter (OTC) covered drugs when prescribed for conditions covered under OHP; or

History

Statutory/Other Authority: ORS 413.032, 413.042, 414.065, 414.330 - 414.414, 414.312, 414.316 & 414.325
Statutes/Other Implemented: 414.065, 414.334, 414.361, 414.371, 414.353, 414.354, 414.325 & 414.369
DMAP 27-2026, amend filed 06/29/2026, effective 07/01/2026
DMAP 18-2026, amend filed 05/27/2026, effective 06/01/2026
DMAP 8-2026, amend filed 02/26/2026, effective 03/01/2026
DMAP 89-2025, amend filed 12/15/2025, effective 01/01/2026
DMAP 75-2025, amend filed 09/30/2025, effective 10/01/2025
DMAP 58-2025, amend filed 07/28/2025, effective 08/01/2025
DMAP 45-2025, amend filed 05/21/2025, effective 05/21/2025
DMAP 153-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 119-2024, temporary amend filed 08/28/2024, effective 09/01/2024 through 02/27/2025
DMAP 109-2024, amend filed 07/01/2024, effective 07/01/2024
DMAP 87-2024, amend filed 05/01/2024, effective 05/01/2024
DMAP 84-2024, amend filed 04/04/2024, effective 04/04/2024
DMAP 96-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 83-2023, amend filed 10/31/2023, effective 11/01/2023
DMAP 74-2023, amend filed 08/27/2023, effective 09/01/2023
DMAP 54-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 39-2023, amend filed 04/28/2023, effective 05/01/2023
DMAP 10-2023, amend filed 03/28/2023, effective 04/01/2023
DMAP 95-2022, temporary amend filed 12/27/2022, effective 01/01/2023 through 06/24/2023
DMAP 87-2022, amend filed 12/13/2022, effective 12/20/2022
DMAP 75-2022, temporary amend filed 09/29/2022, effective 10/01/2022 through 12/27/2022
DMAP 64-2022, temporary amend filed 06/29/2022, effective 07/01/2022 through 12/27/2022
DMAP 61-2022, amend filed 06/26/2022, effective 06/27/2022
DMAP 50-2022, temporary amend filed 04/27/2022, effective 04/27/2022 through 06/25/2022
DMAP 45-2022, temporary amend filed 04/01/2022, effective 04/01/2022 through 06/25/2022
DMAP 54-2021, temporary amend filed 12/29/2021, effective 01/01/2022 through 06/25/2022
DMAP 53-2021, amend filed 12/28/2021, effective 12/28/2021
DMAP 27-2021, temporary amend filed 06/28/2021, effective 07/01/2021 through 12/27/2021
DMAP 25-2021, amend filed 06/24/2021, effective 06/29/2021
DMAP 16-2021, temporary amend filed 04/23/2021, effective 05/01/2021 through 06/29/2021
DMAP 8-2021, temporary amend filed 02/26/2021, effective 03/01/2021 through 06/29/2021
DMAP 69-2020, temporary amend filed 12/28/2020, effective 01/01/2021 through 06/29/2021
DMAP 65-2020, amend filed 12/21/2020, effective 12/27/2020
DMAP 57-2020, temporary amend filed 10/26/2020, effective 11/01/2020 through 12/27/2020
DMAP 41-2020, temporary amend filed 08/25/2020, effective 09/01/2020 through 12/27/2020
DMAP 32-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 29-2020, amend filed 06/24/2020, effective 06/28/2020
DMAP 6-2020, temporary amend filed 02/25/2020, effective 03/01/2020 through 06/28/2020
DMAP 67-2019, temporary amend filed 12/27/2019, effective 01/01/2020 through 06/28/2020
DMAP 54-2019, amend filed 12/12/2019, effective 12/27/2019
DMAP 42-2019, temporary amend filed 10/23/2019, effective 11/01/2019 through 12/27/2019
DMAP 40-2019, temporary amend filed 10/01/2019, effective 10/01/2019 through 12/27/2019
DMAP 31-2019, temporary amend filed 08/13/2019, effective 08/19/2019 through 12/27/2019
DMAP 19-2019, temporary amend filed 06/19/2019, effective 07/01/2019 through 12/27/2019
DMAP 11-2019, amend filed 05/21/2019, effective 06/13/2019
DMAP 9-2019, temporary amend filed 04/09/2019, effective 05/01/2019 through 06/29/2019
DMAP 3-2019, temporary amend filed 03/07/2019, effective 03/07/2019 through 06/29/2019
DMAP 113-2018, temporary amend filed 12/21/2018, effective 01/01/2019 through 06/29/2019
DMAP 112-2018, amend filed 12/21/2018, effective 12/22/2018
DMAP 95-2018, temporary amend filed 10/25/2018, effective 11/01/2018 through 12/27/2018
DMAP 92-2018, temporary amend filed 09/18/2018, effective 10/01/2018 through 12/27/2018
DMAP 85-2018, temporary amend filed 08/15/2018, effective 08/15/2018 through 12/27/2018
DMAP 76-2018, temporary amend filed 06/27/2018, effective 07/01/2018 through 12/27/2018
DMAP 75-2018, amend filed 06/22/2018, effective 06/29/2018
DMAP 26-2018, temporary amend filed 05/02/2018, effective 05/02/2018 through 06/29/2018
DMAP 8-2018, temporary amend filed 02/08/2018, effective 02/08/2018 through 06/29/2018
DMAP 61-2017, temporary amend filed 12/27/2017, effective 01/01/2018 through 06/29/2018
DMAP 52-2017, amend filed 12/26/2017, effective 12/27/2017
DMAP 45-2017, temporary amend filed 11/02/2017, effective 11/02/2017 through 12/27/2017
DMAP 32-2017(Temp), f. & cert. ef. 8-24-17 thru 12-27-17
DMAP 28-2017(Temp), f. 6-30-17, cert. ef. 7-1-17 thru 12-27-17
DMAP 22-2017, f. & cert. ef. 6-29-17
DMAP 11-2017(Temp), f. 3-31-17, cert. ef. 6-1-17 thru 6-29-17
DMAP 10-2017(Temp), f. 3-31-17, cert. ef. 4-1-17 thru 6-29-17
DMAP 5-2017(Temp), f. & cert. ef. 2-21-17 thru 6-29-17
DMAP 79-2016(Temp), f. 12-29-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 68-2016, f. & cert. ef. 12-1-16
DMAP 62-2016(Temp), f. & cert. ef. 10-13-16 thru 12-27-16
DMAP 54-2016(Temp), f. & cert. ef. 8-26-16 thru 12-27-16
DMAP 35-2016(Temp), f. 6-30-16, cert. ef. 7-1-16 thru 12-27-16
DMAP 26-2016, f. 6-24-16, cert. ef. 6-28-16
DMAP 19-2016(Temp), f. 4-28-16, cert. ef. 5-1-16 thru 6-28-16
DMAP 6-2016(Temp), f. 2-11-16, cert. ef. 2-12-16 thru 6-28-16
DMAP 83-2015(Temp), f. 12-23-15, cert. ef. 1-1-16 thru 6-28-16
DMAP 80-2015, f. 12-23-15, cert. ef. 12-27-15
DMAP 58-2015(Temp), f. & cert. ef. 10-9-15 thru 12-27-15
DMAP 44-2015(Temp), f. 8-21-15, cert. ef. 8-25-15 thru 12-27-15
DMAP 41-2015(Temp), f. & cert. ef. 8-7-15 thru 2-2-16
DMAP 36-2015(Temp), f. 6-26-15, cert. ef. 7-1-15 thru 12-27-15
DMAP 34-2015, f. 6-25-15, cert. ef 6-26-15
DMAP 25-2015(Temp), f. 4-17-15, cert. ef. 4-18-15 thru 6-26-15
DMAP 4-2015(Temp), f. & cert. ef. 2-3-15 thru 6-26-15
DMAP 89-2014(Temp), f. 12-31-14, cert. ef. 1-1-15 thru 6-26-15
DMAP 76-2014(Temp), f. & cert. ef. 12-12-14 thru 6-7-15
DMAP 75-2014, f. & cert. ef. 12-12-14
DMAP 62-2014(Temp), f. 10-13-14, cert. ef. 10-14-14 thru 1-11-15
DMAP 49-2014(Temp), f. & cert. ef. 8-13-14 thru 1-11-15
DMAP 46-2014(Temp), f. & cert. ef. 7-15-14 thru 1-11-15
DMAP 38-2014, f. & cert. ef. 6-30-14
DMAP 27-2014(Temp), f. & cert. ef. 5-2-14 thru 6-30-14
DMAP 14-2014(Temp), f. & cert. ef. 3-21-14 thru 9-17-14
DMAP 76-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 43-2013, f. & cert. ef. 8-16-13
DMAP 23-2013(Temp), f. 4-30-13, cert. ef. 5-1-13 thru 8-19-13
DMAP 6-2013(Temp), f. & cert. ef. 2-21-13 thru 8-19-13
DMAP 61-2012, f. 12-27-12, cert. ef. 1-1-13
DMAP 44-2012(Temp), f. & cert. ef. 9-26-12 thru 1-18-13
DMAP 40-2012(Temp), f. & cert. ef. 8-20-12 thru 1-18-13
DMAP 33-2012(Temp), f. 7-18-12, cert. ef. 7-23-12 thru 1-18-13
DMAP 29-2012, f. & cert. ef. 6-21-12
DMAP 27-2012(Temp), f. & cert. ef. 5-14-12 thru 10-15-12
DMAP 23-2012(Temp), f. & cert. ef. 4-20-12 thru 10-15-12
DMAP 18-2012, f. 3-30-12, cert. ef. 4-9-12
DMAP 12-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 27-2011(Temp), f. & cert. ef. 9-30-11 thru 3-15-12
DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 14-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 9-2008, f. 3-31-08, cert. ef. 4-1-08
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
DMAP 4-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 41-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 32-2006, f. 8-31-06, cert. ef. 9-1-06
OMAP 4-2006(Temp), f. & cert. ef. 3-15-06 thru 9-7-06
OMAP 89-2004, f. 11-24-04, cert. ef. 12-1-04
OMAP 74-2004, f. 9-23-04, cert. ef. 10-1-04
OMAP 71-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 9-2004, f. 2-27-04, cert. ef. 3-1-04
OMAP 87-2003(Temp), f. & cert. ef. 12-15-03 thru 5-15-04
OMAP 84-2003, f. 11-25-03, cert. ef. 12-1-03
OMAP 49-2003, f. 7-31-03, cert. ef. 8-1-03
OMAP 43-2003(Temp), f. 6-10-03, cert. ef. 7-1-03 thru 12-15-03
OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03
OMAP 29-2003, f. 3-31-03, cert. ef. 4-1-03
OMAP 66-2002, f. 10-31-02, cert. ef. 11-1-02
OMAP 44-2002, f. & cert. ef. 10-1-02
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 8-1997, f. 3-13-97, cert. ef. 3-15-97
HR 18-1996(Temp), f. & cert. ef. 10-1-96
HR 6-1995, f. 3-31-95, cert. ef. 4-1-95
HR 25-1994, f. & cert. ef. 7-1-94
HR 14-1993, f. & cert. ef. 7-2-93
HR 10-1991, f. & cert. ef. 2-19-91
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0170
AFS 2-1990, f. & cert. ef. 1-16-90
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89

Or. Admin. R. 410-121-0060 How to Get Prior Authorization for Drugs

(1) A prescriber electing to order a drug requiring PA may have any licensed medical personnel in their office request the PA. The PA request may be transmitted to the Oregon Pharmacy Help Desk by any of the following methods:

(a) Call the Oregon Pharmacy Help Desk

(b) FAX the request form shown in the Pharmaceutical Services Supplemental Information on the Oregon Health Authority’s website to the Oregon Pharmacy Help Desk

(2) The status of a PA request received from prescribers or their licensed medical personnel will be reported on the secure MMIS web portal, or by calling the Automated Voice Recognition (AVR) System, within 24 hours of receipt by the Oregon Pharmacy Help Desk

(3) PA approval:

(a) It is the pharmacy personnel’s responsibility to check whether the drugs are covered, whether the client is eligible, and to note restrictions such as date ranges and quantities before dispensing any medications that require PA.

(b) The pharmacy personnel must also check whether the client’s prescribed medications are covered by a managed care plan because an enrollment may have taken place after PA was received. If the client is enrolled in a managed care plan and the pharmacy receiving the PA is not a participating pharmacy provider in the managed care plan’s network, the pharmacy must inform the client that it is not a participating provider in the managed care plan’s network and must also recommend that the client contact his or her managed care plan for a list of pharmacies participating in its network.

(c) After a PA request is approved, the patient will be able to fill the prescription at any Medicaid pharmacy provider, if consistent with all other applicable administrative rules.

(4) If the PA request has been denied, notification to client and prescriber will occur in accordance with OHP General Rules 410-120-1860.

(5) Emergency Need: The Pharmacist may request an emergent or urgent dispensing from the Pharmacy Benefits Manager (PBM) when the client is eligible for covered fee-for-service drug prescriptions.

(a) Clients who do not have a PA pending may receive an emergency dispensing for a 96-hour supply.

(b) Clients who do have a PA pending may receive an emergency dispensing up to a seven-day supply.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 128-2024, minor correction filed 10/14/2024, effective 10/14/2024
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 20-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 2-1995, f. & cert. ef. 2-1-95
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0180
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89

Or. Admin. R. 410-121-0061 Durable Medical Equipment, Medical Supplies, and Medical Surgical Services (Physician Administered Drugs)

Follow the guidelines in the Durable Medical Equipment and Medical Supplies (OAR 410 Division 122), Home Enteral/Parenteral Nutrition and IV Services (OAR chapter 410, division 148), and Medical Surgical Services (OAR chapter 410, division 130) administrative rules and supplemental information for billing and prior authorization of these medical supplies and services. This information is available on the Oregon Health Authority’s web site.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 26-1991, f. & cert. ef. 7-1-91

Or. Admin. R. 410-121-0100 Drug Use Review

(1) Drug Use Review (DUR) in Division of Medical Assistance Programs (Division) is a program designed to measure and assess the proper utilization, quality, therapy, medical appropriateness, appropriate selection and cost of prescribed medication through evaluation of claims data. This is done on both a retrospective and prospective basis. This program shall include, but is not limited to, education in relation to over-utilization, under-utilization, therapeutic duplication, drug-to-disease and drug-to-drug interactions, incorrect drug dosage, duration of treatment and clinical abuse or misuse:

(a) Information collected in a DUR program that identifies an individual is confidential;

(b) Staff of the Drug Use Review (DUR)/Pharmacy & Therapeutics (P&T) Committee and contractors may have access to identifying information to carry out intervention activities approved by the Division. The Division, DUR/P&T Committee or contractors shall adhere to all requirements of the Health Insurance Portability and Accountability Act (HIPAA) and all Division policies relating to confidential client information.

(2) Prospective DUR is the screening for potential drug therapy problems before each prescription is dispensed. It is performed at the point of sale by the dispensing pharmacist:

(a) Dispensing pharmacists must offer to counsel each Division client receiving benefits who presents a new prescription, unless the client refuses such counsel. Pharmacists must document these refusals;

(A) Dispensing pharmacists may offer to counsel the client’s caregiver rather than the client presenting the new prescription if the dispensing pharmacist determines that it is appropriate in the particular instance;

(B) Counseling must be done in person whenever practicable;

(C) If it is not practicable to counsel in person, providers whose primary patient population does not have access to a local measured telephone service must provide access to toll-free services (for example, some mail order pharmacy services) and must provide access to toll-free service for long-distance client calls in relation to prescription counseling;

(b) Prospective DUR is not required for drugs dispensed by Fully Capitated Health Plans (FCHPs);

(c) Oregon Board of Pharmacy rules defining specific requirements relating to patient counseling, record keeping and screening must be followed.

(3) Retrospective DUR is the screening for potential drug therapy problems based on paid claims data. The Division provides a professional drug therapy review for Medicaid clients through this program:

(a)The criteria used in retrospective DUR are compatible with those used in prospective DUR. Retrospective DUR criteria may include Pharmacy Management (Lock-In), Polypharmacy, and Psychotropic Use in Children. Drug therapy review is carried out by pharmacists with the Oregon State University College of Pharmacy, Drug Use Research and Management Program.

(b) If therapy problems are identified, an educational letter is sent to the prescribing provider, the dispensing provider, or both. Other forms of education are carried out under this program with Division approval.

(4) The DUR/P&T Committee is designed to develop policy recommendations in the following areas in relation to Drug Use Review:

(a) Appropriateness of criteria and standards for prospective DUR and needs for modification of these areas. DUR criteria are predetermined elements of health care based upon professional expertise, prior experience, and the professional literature with which the quality, medical appropriateness, and appropriateness of health care service may be compared.

(b) The use of different types of education and interventions to be carried out or delegated by the DUR/P&T Committee and the evaluation of the results of this portion of the program; and

(A) DUR/P&T Committee Activities;

(i) A description of how pharmacies comply with prospective DUR;

(ii) Detailed information on new criteria and standards in use; and

(iii) Changes in state policy in relation to DUR requirements for residents in nursing homes;

(B) A summary of the education/intervention strategies developed; and

(C) An estimate of the cost savings in the pharmacy budget and indirect savings due to changes in levels of medical visits and hospitalizations.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 61-2012, f. 12-27-12, cert. ef. 1-1-13
DMAP 42-2012(Temp), f. & cert. ef. 9-12-12 thru 3-10-13
DMAP 12-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12
DMAP 27-2011(Temp), f. & cert. ef. 9-30-11 thru 3-15-12
DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 38-1992, f. 12-31-92, cert. ef. 1-1-93
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-121-0111 Pharmacy and Therapeutics Committee

(1) The Drug Use Review (DUR)/Pharmacy and Therapeutics Committee (P&T Committee) is composed of 11 individuals appointed by the director of the Oregon Health Authority (Authority) pursuant to ORS 414.353.

(2) The P&T Committee shall advise the Oregon Health Authority (Authority) on the following:

(a) Implementation of the medical assistance program retrospective and prospective programs, including the type of software programs to be used by the pharmacist for prospective drug use review and the provisions of the contractual agreement between the state and any entity involved in the retrospective program;

(b) Implementation of the Practitioner Managed Prescription Drug Plan (PMPDP);

(d) Development of and application of the criteria and standards to be used in retrospective and prospective drug use review and safety edit programs in a manner that ensures that such criteria and standards are based on compendia, relevant guidelines obtained from professional groups through consensus-driven processes, the experience of practitioners with expertise in drug therapy, data and experience obtained from drug utilization review program operations. The P&T Committee must have an open professional consensus process, establish an explicit ongoing process for soliciting and considering input from interested parties, and make timely revisions to the criteria and standards based on this input and scheduled reviews;

(e) Development, selection and application of and assessment for interventions being educational and not punitive in nature for medical assistance program prescribers, dispensers and patients.

(3) The P&T Committee shall make recommendations to the Authority, subject to approval by the Director or the Director's designee, for drugs to be included on any PDL adopted by the Authority and on the PMPDP. The P&T Committee shall also recommend all utilization controls, prior authorization requirements or other conditions for the inclusion of a drug on the PDL.

(4) The P&T Committee shall, with the approval of the Director or designee, do the following:

(a) Publish an annual report;

(b) Publish and disseminate educational information to prescribers and pharmacists regarding the P&T Committee and the drug use review programs, including information on the following:

(A) Identifying and reducing the frequency of patterns of fraud, abuse or inappropriate or medically unnecessary care among prescribers, pharmacists and recipients;

(B) Potential or actual severe or adverse reactions to drugs;

(D) Overutilization or underutilization;

(E) Appropriate use of generic products;

(F) Therapeutic duplication;

(G) Drug-disease contraindications;

(H) Drug-drug interactions;

(I) Drug allergy interactions;

(J) Clinical abuse and misuse.

(K) Patient safety

(c) Adopt and implement procedures designed to ensure the confidentiality of any information that identifies individual prescribers, pharmacists or recipients and that is collected, stored, retrieved, assessed or analyzed by the P&T Committee, staff of the P&T Committee, contractors to the P&T Committee or the Authority.

History

Statutory/Other Authority: ORS 413.042 & 414
Statutes/Other Implemented: ORS 414.065, 414.353 & 414.354
DMAP 71-2025, amend filed 09/25/2025, effective 10/01/2025
DMAP 5-2014, f. & cert. ef. 1-28-14
DMAP 40-2013(Temp), f. & cert. ef. 8-1-13 thru 1-28-14
DMAP 61-2012, f. 12-27-12, cert. ef. 1-1-13
DMAP 42-2012(Temp), f. & cert. ef. 9-12-12 thru 3-10-13
SPD 12-2012(Temp) , f. 8-31-12, cert. ef. 9-1-12 thru 2-28-13

Or. Admin. R. 410-121-0135 Pharmacy Management Program

(1) The Pharmacy Management Program promotes the appropriate use of quality pharmaceutical services by identifying and correcting overutilization of services.

(2) The Pharmacy Management Program limits some fee-for-service clients to receiving their prescription drugs through the following sources:

(a) A single retail pharmacy to pick up prescriptions;

(b) The Division of Medical Assistance Program (Division) mail order pharmacy contractor; and

(3) The Division will not include the following clients in the Pharmacy Management Program:

(a) Members enrolled in a Coordinated Care Organization;

(b) Clients with Medicare drug coverage in addition to OHP;

(d) Inpatients or residents in a hospital, nursing facility, other medical institution or long term care facility.

(4) The Division will consider referrals of potential Pharmacy Management Program clients from the following sources:

(a) Providers;

(b) Division staff; and

(5) Reasons for referring a client to the Division for potential enrollment in the Pharmacy Management Program shall be limited to factors that indicate possible overutilization or drug misuse, or that raise concern for patient safety. Those factors are:

(a) Use of three or more pharmacies during the prior six months;

(b) Fills prescriptions from more than one prescriber for the same or comparable medications; or

(d) Exhibits behaviors or patterns of behavior that the Pharmacy and Therapeutics Committee has identified as indicative of intentional overutilization or misuse.

(6) Clients referred to the Division for potential enrollment in the Pharmacy Management Program shall be enrolled in the program only when a licensed pharmacist appointed by the Division conducts a review and concludes the individual utilized pharmaceutical items or services at a frequency or amount that is not medically necessary based on factors including, but not limited to, those described in subsection (5) of this rule.

(7) When the Division concludes enrollment in the Pharmacy Management Program is appropriate as described in subsection (6), the Division shall send the client a notice that provides the following information:

(a) The Division plans to require that the client use a designated pharmacy for a 12-month period;

(b) The specific date when the requirement will begin;

(c) An explanation of the reason for enrollment in the Pharmacy Management Program, and the benefits of enrollment in the Pharmacy Management Program; and

(d) The client’s right to request the following, within 45 days of the date of the notice:

(A) A different designated pharmacy; and

(B) An administrative hearing to appeal the Division's decision to enroll the client into the Pharmacy Management Program.

(8) Changing the Pharmacy Management Program client’s enrolled pharmacy:

(a) Clients may change their enrolled pharmacy if they:

(A) Move out of area;

(B) Are reapplying for OHP benefits; or

(C) Are denied access to pharmacy services by their selected pharmacy for reasons other than the Pharmacy Management Program factors identified by the Division;

(b) Clients cannot change their choice of pharmacy more than once every 3 months.

(9) Pharmacy Management Program clients may receive drugs from a different pharmacy if the client urgently needs to fill a prescription and the enrolled pharmacy:

(a) Is not available;

(b) Does not have the prescribed drug in stock; or

(c) Is more than 50 miles away from the client’s location at the time the prescription needs to be filled. However, DMAP may deny coverage if the client frequently fills prescriptions out of the area of the enrolled pharmacy.

(10) Call the Oregon Pharmacy Help Desk for authorization to fill a prescription in the situations described in (9)(a)–(c) above.

(11) The client’s appeal rights and the process for appealing a Division decision to enroll a client in the Pharmacy Management Program are found in OAR 410-120-1860. If the client requests an administrative hearing before the effective date of the client notice and requests that the services be continued, the Authority shall continue the services pursuant to OAR 410-120-1865.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065 & OL 2013 Ch. 467 Sec. 2
DMAP 77-2015, f. 12-22-15, cert. ef. 1-1-16
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 9-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 26-2002, f. 6-14-02 cert. ef. 7-1-02

Or. Admin. R. 410-121-0143 Client Confidentiality

Pharmacists are responsible for maintaining the confidentiality of client information in compliance with HIPAA standards. Facilities shall provide adequate privacy for patient consultations.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
HR 16-1992, f. & cert. ef. 7-1-92

Or. Admin. R. 410-121-0145 Prescription Requirements

(1) Division of Medical Assistance Programs (Division) will make payment for covered drugs supplied on drug order or prescription of a licensed practitioner and dispensed by a pharmacist. Dispensings include new prescriptions, refills of existing prescriptions, and over-the-counter (OTC) medications.

(2) Each drug order or prescription filled for a Division client must:

(a) Be retained in the pharmacy's file at the pharmacy’s place of business; and,

(b) All drug orders or prescriptions must comply with the Oregon State Board of Pharmacy rules and regulations as listed in OAR 855 Division 041.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 71-2025, amend filed 09/25/2025, effective 10/01/2025
DMAP 2-2010, f. 2-1-10, cert. ef. 2-5-10
DMAP 9-2008, f. 3-31-08, cert. ef. 4-1-08
DMAP 4-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 25-1994, f. & cert. ef. 7-1-94
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0200
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0020
AFS 4-1989, f. 1-31-89, cert. ef. 2-1-89
AFS 53-1985, f. 9-20-85, ef. 10-1-85
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 44-1982, f. 4-30-82, ef. 5-1-82
PWC 869, f. 12-30-77, ef. 1-1-78
PWC 831, f. 2-18-77, ef. 3-1-77
PWC 818(Temp), f. 10-22-76, ef. 11-1-76

Or. Admin. R. 410-121-0146 Dispensing Limitations

(1) The Authority shall reimburse the pharmacy for dispensed medication the lesser of:

(a) The quantity indicated by the prescriber on the prescription;

(b) The quantity indicated by the Authority’s dispensing limitations as outlined in this rule; or

(2) The pharmacy may only dispense less than the prescribed quantity when the prescribed quantity exceeds the Authority’s dispensing limitations, or when a lesser quantity is needed for Prescription Synchronization.

(3) The pharmacy may, at the member’s direction, dispense less than the prescribed quantity of a maintenance medication in order to align the refill dates if the member has received the same dose for two months or more.

(4) Unless otherwise specified in this rule, the Authority shall not reimburse claims for medications exceeding a 34-day supply.

(5) All pharmacy providers shall be reimbursed for up to a 100-day supply of preferred drugs in the following Standard Therapeutic Classes of medications:

(a) Ataractics, Tranquilizers — 07;

(b) Psychostimulants, Antidepressants — 11;

(6) Exceptions to the 34-day supply do not apply to claims for the following Standard Therapeutic Classes of medications. Claims exceeding a 34-day supply for these medications shall not be reimbursed under any circumstances:

(a) Muscle Relaxants — 08;

(b) CNS Stimulants — 10;

(d) Narcotic Analgesics — 40;

(e) Sedative Barbiturate — 46;

(f) Sedative Non-Barbiturate — 47.

(7) The Authority may reimburse for more than a 34-day supply if the medication’s original package size cannot be divided or when primary insurance (third party liability) pays for a larger day supply.

(8) Except for medications listed in subsections (5) and (6) of this rule, claims for up to a 100-day supply of the following types of medications may be reimbursed to the Authority’s mail order pharmacy contractor, Indian Health mail order pharmacy providers, and 340B providers:

(a) A PDL generic; and

(b) A generic drug not on the PDL, costing $10 per month or less.

(9) All pharmacy providers shall be reimbursed for up to a 365-day supply of family planning drugs.

(10) Notwithstanding subsection (4) and subsection (11) of this rule, the Authority shall reimburse all pharmacy providers for up to a 365‑day supply of preferred drugs within the following Standard Therapeutic Classes, provided that the specific drug dispensed can be stored at room temperature. This subsection is a standalone exception to the day supply limitations in subsections (5), (7), and (8). If the medication is a controlled substance, reimbursement is limited to the maximum day supply permitted under state and federal law. The applicable Standard Therapeutic Classes are:

(a) Estrogen — Standard Therapeutic Class 61

(b) Progesterone — Standard Therapeutic Class 62

(d) Androgens - Standard Therapeutic Class 60

(e) Gonadotropin-releasing hormone (GNRH) agonists – Specific Therapeutic Classes P1M, P1P, V1O.

(11) Selected medications identified by the Authority shall be limited to a 15-day supply for initial fills. The Authority has identified these medications as having high side effect profiles, high discontinuation rates, or requiring frequent dose adjustments.

(12) The pharmacy should provide a minimum of a one-month supply of insulin per dispensing once diabetes management has been stabilized.

(13) For vaccines available in multiple dose packaging, the Division shall allow a dispensing fee for each multiple dose. When vaccines are administered at the pharmacy, refer to Oregon Administrative Rule (OAR) 410-121-0185.

(14) Splitting prescriptions:

(a) For compounded prescriptions, pharmacy providers must bill components of the prescription separately.

(b) When a pharmacy provider receives third party payments for compounded prescriptions, the payments must be split and applied equally to each component;

(c) The Authority shall consider any other form of prescription splitting as a billing offense and take appropriate action as described in the General Rules (OAR 410 division 120).

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 30-2026, amend filed 07/08/2026, effective 07/09/2026
DMAP 71-2025, amend filed 09/25/2025, effective 10/01/2025
DMAP 96-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 76-2015, f. 12-22-15, cert. ef. 1-1-16
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10
DMAP 6-2010(Temp), f. & cert. ef. 4-1-10 thru 6-30-10
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 19-2004(Temp), f. & cert. ef. 3-15-04 thru 4-14-04
OMAP 7-2004, f. 2-13-04, cert. ef. 3-15-04
OMAP 74-2002, f. 12-24-02, cert. ef. 1-1-03
OMAP 1-2002, f. & cert. ef. 2-15-02
OMAP 61-2001(Temp), f. 12-13-01, cert. ef. 12-15-01 thru 3-15-02
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 20-1997, f. & cert. ef. 9-12-97
HR 27-1996, f. 12-11-96, cert. ef. 12-15-96
HR 6-1996(Temp), f. & cert. ef. 8-1-96
HR 25-1994, f. & cert. ef. 7-1-94
HR 16-1992, f. & cert. ef. 7-1-92
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0210
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0090
AFS 4-1989, f. 1-31-89, cert. ef. 2-1-89
AFS 15-1987, f. 3-31-87, cert. ef. 4-1-87
AFS 52-1986, f. & cert. ef. 7-2-86
AFS 53-1985, f. 9-20-85, cert. ef. 10-1-85
AFS 26-1984, f. & cert. ef. 6-19-84
AFS 12-1984, f. 3-16-84, cert. ef. 4-1-84
AFS 99-1982, f. 10-25-82, cert. ef. 11-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 44-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 70-1981, f. 9-30-81, cert. ef. 10-1-81
PWC 869, f. 12-30-77, cert. ef. 1-1-78
PWC 831, f. 2-18-77, cert. ef. 3-1-77
PWC 818(Temp), f. 10-22-76, cert. ef. 11-1-76

Or. Admin. R. 410-121-0147 Exclusions and Limitations

(1) The following items are not covered for payment by the Division of Medical Assistance Programs (Division) Pharmaceutical Services Program:

(a) Except as provided in section (2) of this rule, drug products for diagnoses below the funded line on the Health Evidence Review Commission (HERC) Prioritized List of Health Services or an excluded service under Oregon Health Plan (OHP) coverage;

(b) Home pregnancy kits;

(d) Expired drug products;

(e) Drug products from non-rebatable manufacturers, with the exception of selected oral nutritionals, vitamins, and vaccines;

(f) Active Pharmaceutical Ingredients (APIs) and Excipients as described by Centers for Medicare and Medicaid (CMS);

(g) Drug products that are not assigned a National Drug Code (NDC) number;

(h) Drug products that are not approved by the Food and Drug Administration (FDA);

(i) Drug products dispensed for Citizenship Waived Medical (CWM) client benefit type except when prescribed as an emergency medical service as defined by OAR 410-134-0003(3). The CWM benefit plan ended on June 30, 2023;

(j) Drug Efficacy Study Implementation (DESI) drugs (see OAR 410-121-0420);

(k) Medicare Part D covered drugs or classes of drugs for fully dual eligible clients (see OAR 410-120-1200 & 410-120-1210).

(l) Drug products prescribed to establish or reestablish fertility or pregnancy;

(m) Drug products when prescribed for the treatment of sexual or erectile dysfunction;

(n) Drug products when prescribed for weight loss; and

(o) Drug products when primarily prescribed for cosmetic purposes or hair growth.

(2) The Division shall cover drug products for diagnoses below the funded line on the HERC Prioritized List of Health Services when such coverage is required through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in Chapter 410 Division 151.

(3) The Division shall cover drug products from non-rebateable manufacturers under any one or a combination of the following circumstances:

(a) Coverage is required through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in Chapter 410 Division 151;

(b) The drug is a vaccine; or

(4) Effective on or after April 1, 2008, Section 1903(i) of the Social Security Act requires that written (nonelectronic) prescriptions for covered outpatient drugs for Medicaid clients be executed on a tamper-resistant pad in order to be eligible for federal matching funds. To meet this requirement, the Division shall only reimburse for covered Medicaid outpatient drugs only when the written (nonelectronic) prescription is executed on a tamper-resistant pad, or the prescription is electronically submitted to the pharmacy.

(5) Drugs requiring a skilled medical professional for safe administration shall be billed by the medical professional’s office; unless otherwise specified by the Division.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 71-2025, amend filed 09/25/2025, effective 10/01/2025
DMAP 87-2024, amend filed 05/01/2024, effective 05/01/2024
DMAP 96-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 25-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10
DMAP 9-2008, f. 3-31-08, cert. ef. 4-1-08
OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 22-1997, f. & cert. ef. 10-1-97
HR 2-1995, f. & cert. ef. 2-1-95
HR 25-1994, f. & cert. ef. 7-1-94
HR 11-1994, f. 2-25-94, cert. ef. 2-27-94
HR 34-1993(Temp), f. & cert. ef. 12-1-93
HR 22-1993(Temp),f. & cert. ef. 9-1-93

Or. Admin. R. 410-121-0148 Dispensing in a Nursing Facility or Community Based Care Living Facility

A pharmacy serving Division of Medical Assistance Program’s (Division) clients in a nursing facility or a Community Based Care Living Facility must dispense medication in a manner consistent with Board of Pharmacy rules as set out in OAR 855-041.

(1) For the purposes of this rule, “Long term care facility” includes skilled nursing facilities and intermediate care facilities consistent with the definitions in ORS 443.400 to 443.455.

(2) An intermediate care facility is a facility providing regular health related care and services to individuals at a level above room and board, but less than hospital or skilled nursing levels ORS 442.015.

History

Statutory/Other Authority: 404.110, 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 18-2004, f. 3-15-04, cert. ef. 4-1-04
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0230
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0070
AFS 52-1986, f. & cert. ef. 7-2-86
AFS 16-1985, f. 3-26-85, cert. ef. 5-1-85
AFS 58-1983, f. 11-30-83, cert. ef. 1-1-84
AFS 99-1982, f. 10-25-82, cert. ef. 11-1-82
AFS 83-1982(Temp), f. & cert. ef. 9-2-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 44-1982, f. 4-30-82, cert. ef. 5-1-82
PWC 869, f. 12-30-77, cert. ef. 1-1-78
PWC 831, f. 2-18-77, cert. ef. 3-1-77
PWC 818(Temp), f. 10-22-76, cert. ef. 11-1-76

Or. Admin. R. 410-121-0150 Billing Requirements

(1) All 340B covered entities that fill Medicaid patient prescriptions with drugs purchased at the prices authorized under Section 340B of the Public Health Service Act shall bill Medicaid at the actual acquisition cost, plus the entity’s assigned professional dispensing fee.

(2) Pharmacies that purchase drugs at Nominal Price outside of 340B or the Federal Supply Schedule shall bill their actual acquisition cost.

(3) With the exception of Indian Health Service pharmacies and Tribal 638 pharmacies, pharmacies who purchase drugs through the Federal Supply Schedule must bill their actual acquisition cost. Refer to AI/AN rules OAR chapter 410, division 146 for billing rules for Indian Health Service pharmacies and Tribal 638 pharmacies.

(4) When billing the Health Systems Division (Division) for drug products, the provider:

(a) May not bill in excess of the usual and customary charge to the general public:

(A) The sum of charges for both the product cost and dispensing fee may not exceed a pharmacy's usual and customary charge for the same or similar service;

(B) When billing the Division for a prescription, the pharmacy shall bill the lowest amount accepted from any member of the general public who participates in the pharmacy provider's savings or discount program;

(b) Shall indicate the National Drug Code (NDC) as it appears on the package from which the prescribed medications are dispensed;

(d) Unless specifically provided by another rule, when clients have other insurances, shall bill the other insurances as primary and the Division as secondary;

(e) When clients have Medicare prescription drug coverage, shall bill Medicare as primary and the Division as secondary.

(5) When submitting a paper claim, the provider shall furnish accurately all information required on the 1.2 Universal Claims Form.

(6) The prescribing provider’s National Provider Identifier (NPI) is mandatory on all fee-for-service client drug prescription claims. Claims shall deny for a missing or invalid prescriber NPI. An exception to this includes but is not limited to a prescribing provider who does not have an NPI for billing, but who prescribes fee-for-service prescriptions for clients under Coordinated Care Organizations (CCOs), prepaid health plans (PHPs), long-term care, or other capitated contracts. This provider is to be identified with the:

(a) Non-billing NPI-assigned for prescription writing only;

(b) Clinic or facility NPI until an individual NPI is obtained; or

(c) Supervising physician’s NPI when billing for prescriptions written by the physician associate, physician students, physician interns, or medical professionals who have prescription writing authority.

(7) Billing for Death With Dignity services:

(a) Claims for Death With Dignity services may not be billed through the Point-of-Sale system;

(b) Services shall be billed directly to the Division, even if the client is in a CCO or PHP;

(c) Prescriptions shall be billed on a 1.2 Universal Claims Form paper claim form using an NDC number. Claims shall be submitted to the address indicated in the Division’s Supplemental Information for Pharmaceutical Services.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 4-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 11-2018, amend filed 03/02/2018, effective 03/02/2018
DMAP 23-2011, f. 8-24-11, cert. ef. 9-1-11
DMAP 14-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
DMAP 4-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 9-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 18-2004, f. 3-15-04, cert. ef. 4-1-04
OMAP 49-2003, f. 7-31-03, cert. ef. 8-1-03
OMAP 43-2003(Temp), f. 6-10-03, cert. ef. 7-1-03 thru 12-15-03
OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03
OMAP 7-2002, f. & cert. ef. 4-1-02
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 5-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 25-1999, f. & cert. ef. 6-4-99
OMAP 11-1999(Temp), f. & cert. ef. 4-1-99 thru 9-1-99
OMAP 44-1998(Temp), f. 12-1-98, cert. ef. 12-1-98 thru 5-1-99
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0240
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0093
AFS 15-1987, f. 3-31-87, ef. 4-1-87

Or. Admin. R. 410-121-0155 Reimbursement

(1) The Division shall pay the lesser of the provider's billed amount or the ingredient cost plus a professional dispensing fee.

(2) The ingredient cost is established by the Division as follows:

(a) The Oregon Average Actual Acquisition Cost (OR-AAAC) of the drug;

(b) In cases where no OR-AAAC is available, the National Average Drug Acquisition Cost (NADAC);

(3) For ingredient cost for trade name forms of multiple source products:

(a) Except as provided in (3)(b) of this rule, the Division shall apply the OR-AAAC or NADAC of the generic form when a trade name form of a multiple source product is dispensed;

(b) The Division shall pay the OR-AAAC or NADAC of the trade name form only when the prescribing practitioner certifies the trade version is required or when the brand drug is listed on the Division’s Preferred Drug List.

(4) The Division shall revise its OR-AAAC weekly. Pharmacies must make available to the Division or its contractor any information necessary to determine the pharmacy’s actual acquisition cost of drug products dispensed to the Division’s clients.

(5) The OR-AAAC shall serve as the basis for reimbursement. Individual pharmacies, other than Indian Health Service, Tribal 638 or Urban Indian Health Program pharmacies, are required to participate in an OR-AAAC survey conducted by the Division or its contractor not more than one time per every 18 to 24-month period. Pharmacies that do not respond to OR-AAAC survey requests may be subject to disenrollment as providers for the Oregon Health Plan.

(6) If a provider is unable to purchase a particular drug product at the OR-AAAC, the provider shall report this to the Division or its contractor for further review through a dispute resolution process. Providers may submit inquiries via telephone, facsimile, via electronic mail, or the contractor’s secure web site: https://myersandstauffer.com/client-portal/oregon/:

(a) The Division or its contractor shall respond to all inquiries or complaints within 24 hours and resolve the issue within five business days;

(b) The pricing dispute resolution process shall include the Division or its contractor verifying the accuracy of pricing to ensure consistency with marketplace pricing and drug availability;

(7) The Division restricts claims for hemophilia blood factors to Federally Supported Hemophilia Treatment Centers that are a Center of Excellence, as provided in OAR 410-120-0000.This restriction does not apply to clients with other insurances or Medicare in addition to OHP. The Federally Approved provider of factors, non-factor or gene therapy for people with bleed disorders is the Hemophilia Center at OHSU. Questions concerning bleeding disorder case management shall be directed to this provider by calling: 877-346-0640.

(8) No professional dispensing fee is allowed for dispensing pill splitters/cutters or diabetic supplies and glucose monitors.

(9) Payment for pill splitters/cutters with a National Drug Code (NDC) number shall be reimbursed at the lesser of the billed amount or the ingredient cost and:

(a) A practitioner prescription is required; and

(b) The Division shall pay only for one pill splitter/cutter per client in a twelve-month period.

(10) A prescription is required for glucose monitors and related diabetic supplies.

(11) Payment for glucose monitors and related diabetic supplies billed with an NDC shall be reimbursed at a percentage of Medicare’s rate for the HCPCS procedure code. The Division’s reimbursement rates are listed in the Division’s fee schedule located at: http://www.oregon.gov/OHA/healthplan/pages/feeschedule.aspx.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 71-2025, amend filed 09/25/2025, effective 10/01/2025
DMAP 96-2022, amend filed 12/28/2022, effective 01/01/2023
DMAP 69-2022, minor correction filed 08/16/2022, effective 08/16/2022
DMAP 11-2018, amend filed 03/02/2018, effective 03/02/2018
DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 14-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 5-2009(Temp), f. 3-26-09, cert. ef. 4-1-09 thru 9-25-09
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05
OMAP 18-2004, f. 3-15-04, cert. ef. 4-1-04
OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03
OMAP 32-2002, f. & cert. ef. 8-1-02
OMAP 1-2002, f. & cert. ef. 2-15-02
OMAP 61-2001(Temp), f. 12-13-01, cert. ef. 12-15-01 thru 3-15-02
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 20-1991, f. & cert. ef. 4-16-91
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0250
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0100
AFS 12-1987, f. 3-3-87, cert. ef. 4-1-87
AFS 52-1986, f. & cert. ef. 7-2-86
AFS 42-1986(Temp), f. 6-10-86, cert. ef. 7-1-86
AFS 53-1985, f. 9-20-85, cert. ef. 10-1-85
AFS 18-1984, f. 4-23-84, cert. ef. 5-1-84
AFS 56-1983, f. 11-17-83, cert. ef. 12-1-83
AFS 51-1983(Temp), f. 9-30-83, cert. ef. 10-1-83
AFS 13-1983, f. & cert. ef. 3-21-83
AFS 113-1982(Temp), f. 12-28-82, cert. ef. 1-1-83
AFS 99-1982, f. 10-25-82, cert. ef. 11-1-82
AFS 74-1982(Temp), f. 7-22-81, cert. ef. 8-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 44-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 70-1981, f. 9-30-81, cert. ef. 10-1-81
AFS 53-1981(Temp), f. & cert. ef. 8-14-81
AFS 35-1981(Temp), f. 6-26-81, cert. ef. 7-1-81
AFS 15-1981, f. 3-5-81, cert. ef. 4-1-81
AFS 41-1979, f. & cert. ef. 11-1-79
AFS 15-1979(Temp), f. 6-29-79, cert. ef. 7-1-79
PWC 869, f. 12-30-77, cert. ef. 1-1-78
PWC 858, f. 10-14-77, cert. ef. 11-1-77
PWC 846(Temp), f. & cert. ef. 7-1-77
PWC 831, f. 2-18-77, cert. ef. 3-1-77
PWC 818(Temp), f. 10-22-76, cert. ef. 11-1-76

Or. Admin. R. 410-121-0157 Participation in the Medicaid Drug Rebate Program

(1) The Oregon Medicaid Pharmaceutical Services Program is a participant in the Centers for Medicare and Medicaid Services (CMS) Medicaid Drug Rebate Program, created by the Omnibus Budget Reconciliation Act (OBRA) of 1990. The Patient Protection and Affordable Care Act (PPACA) enacted on March 23,2010 and the Health Care and Education Reconciliation Act of 2010, (HCERA) enacted on March 30, 2010, together called the Affordable Care Act, requires the Division to collect drug rebates for covered outpatient drugs dispensed to enrollees of Medicaid managed care organizations, (MCOs). The Medicaid Drug Rebate Program requires a drug manufacturer to enter into and have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services for States to receive federal funding for outpatient drugs dispensed to Medicaid patients. The drug rebate program is administered by CMS's Center for Medicaid and State Operations (CMSO). Pharmaceutical companies participating in this program have signed agreements with CMS to provide rebates to the Division of Medical Assistance Programs (Division) on all their drug products. The Division will reimburse providers only for outpatient drug products manufactured or labeled by companies participating in this program.

(2) Documents in rule by reference: Names and Labeler Code numbers for participants in the Medicaid Drug Rebate Program are the responsibility of and maintained by CMS. The Division receives this information from CMS in the form of numbered and dated Releases. The Division includes in rule by reference, the CMS Releases online at: https://www.medicaid.gov/medicaid/prescription-drugs/program-releases/index.html.

(3) Retroactive effective dates: The CMS Medicaid Drug Rebate Program experiences frequent changes in participation and often this information is submitted to the Division after the effective date(s) of some changes. Therefore, certain participant additions and deletions may be effective retroactively. See specific instructions in the CMS Releases for appropriate effective date(s) of changes.

(4) The Division contracts with a Pharmacy Benefit Manager (PBM) to manage the Medicaid Rebate Dispute Resolution program. Pharmacy providers must verify the accuracy of their Medicaid pharmacy claims with the PBM within 30 days of request in instances where drug manufacturers dispute their claim information. Verification can be photocopies of drug invoices showing that the billed products were in stock during the time of the date of service.

(5) The actual National Drug Code (NDC) dispensed and the actual metric decimal quantity dispensed, must be billed.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 36-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 49-2006, f. 12-28-06, cert. ef. 1-1-07
OMAP 12-2006, f. 5-26-06, cert. ef. 6-1-06
OMAP 7-2006(Temp), f. 3-29-06, cert. ef. 4-1-06 thru 9-15-06
OMAP 5-2006, f. 3-22-06, cert. ef. 4-1-06
OMAP 55-2005, f. 10-25-05, cert. ef. 11-1-05
OMAP 30-2005, f. & cert. ef. 6-6-05
OMAP 7-2005(Temp), f. 3-1-05, cert. ef. 4-1-05 thru 8-1-05
OMAP 6-2005, f. 3-1-05, cert. ef. 3-31-05
OMAP 1-2005(Temp), f. & cert. ef. 1-14-05 thru 6-1-05
OMAP 82-2004, f. 10-29-04, cert. ef. 11-1-04
OMAP 53-2004(Temp), f. & cert. ef. 9-10-04 thru 2-15-05
OMAP 42-2004, f. 6-24-04 cert. ef. 7-1-04
OMAP 31-2004(Temp), f. & cert. ef. 5-14-04 thru 10-15-04
OMAP 24-2004, f. & cert. ef. 3-30-04
OMAP 5-2004(Temp), f. & cert. ef. 2-4-04 thru 6-15-04
OMAP 74-2003, f. & cert. ef. 10-1-03
OMAP 74-2003, f. & cert. ef. 10-1-03
OMAP 48-2003, f. & cert. ef. 7-7-03
OMAP 39-2003(Temp), f. & cert. ef. 5-15-03
OMAP 38-2003, f. & cert. ef. 5-9-03
OMAP 6-2003(Temp), f. & cert. ef. 2-14-03 thru 7-1-03
OMAP 67-2002(Temp), f. & cert. ef. 11-1-02 thru 3-15-03
OMAP 34-2002(Temp), f. & cert. ef. 8-14-02 thru 1-15-03
OMAP 20-2002(Temp), f. & cert. ef. 5-15-02 thru 10-1-02
OMAP 16-2002(Temp), f. & cert. ef. 4-12-02 thru 9-1-02
OMAP 4-2002(Temp), f. & cert. ef. 3-5-02 thru 8-1-02
OMAP 66-2001(Temp), f. 12-28-01, cert. ef. 1-1-02 thru 5-15-02
OMAP 57-2001(Temp), f. 11-28-01, cert. ef. 12-1-01 thru 4-15-02
OMAP 56-2001(Temp), f. & cert. ef. 11-1-01 thru 4-15-02
OMAP 48-2001(Temp), f. 9-28-01, cert. ef. 10-1-01 thru 3-1-02
OMAP 27-2001(Temp), f. 7-30-01, cert. ef. 8-1-01 thru 1-26-02
OMAP 25-2001(Temp), f. 6-28-01, cert. ef. 7-1-01 thru 12-1-01
OMAP 24-2001(Temp), f. 5-9-01, cert. ef. 5-10-01 thru 11-1-01
OMAP 3-2001, f. & cert. ef. 3-16-01
OMAP 43-2000(Temp), f. 12-29-00, cert. ef. 1-1-01 thru 5-1-01
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 2-1998, f. 1-30-98, cert. ef. 2-1-98
HR 27-1997, f. & cert. ef. 12-1-97
HR 22-1997, f. & cert. ef. 10-1-97
HR 23-1995, f. 12-29-95, cert. ef. 1-1-96
HR 14-1995, f. 6-29-95, cert. ef. 7-1-95
HR 6-1995, f. 3-31-95, cert. ef. 4-1-95
HR 2-1995, f. & cert. ef. 2-1-95
HR 25-1994, f. & cert. ef. 7-1-94
HR 17-1994, f. & cert. ef. 4-1-94
HR 24-1993, f. & cert. ef. 10-1-93
HR 14-1993, f. & cert. ef. 7-2-93
HR 7-1993 (Temp), f. & cert. ef. 4-1-93
HR 4-1993, f. 3-10-93, cert. ef. 3-11-93
HR 34-1992, f. & cert. ef. 12-1-92
HR 31-1992, f. & cert. ef. 10-1-92
HR 21-1992, f. 7-31-92, cert. ef. 8-1-92 HR 13-1992, f. & cert. ef. 6-1-92
HR 1-1992, f. & cert. ef. 1-2-92
HR 50-1991(Temp), f. & cert. ef. 10-29-91
HR 45-1992, f. & cert. ef. 10-16-91 HR 36-1991(Temp), f. 9-16-91, cert. ef. 10-1-91
HR 31-1991, f. & cert. ef. 7-16-91
HR 23-1991(Temp), f. 6-14-91, cert. ef. 6-17-91 HR 22-1991, f. & cert. ef. 5-16-91
HR 16-1991(Temp), f. 4-12-91, cert. ef. 4-15-91

Or. Admin. R. 410-121-0160 Dispensing Fees

(1) This rule does not apply to IHS and Tribal 638 pharmacies that are reimbursed according to the IHS All-Inclusive Rate (AIR) methodology as described in OAR 410-146-0200.

(2) Effective December 1, 2024, professional dispensing fees allowable for services shall be reimbursed as follows:

(a) All 340B pharmacies operated by a 340B covered entity shall be reimbursed at a rate of $20.86 per claim;

(b) Except as described in OAR 410-121-0160(2)(c), all other enrolled pharmacies shall be reimbursed based on the individual pharmacy’s annual claims volume as follows:

(A) Less than 40,000 claims a year (“lowest volume tier”) = $16.87;

(B) Between 40,000 and 79,999 claims per year = $11.93;

(c) Critical Access Pharmacy (CAP) as defined in OAR 431-121-2000(4) shall be reimbursed at the lowest volume tier regardless of volume. The Division shall apply the CAP designation according to the most recently posted quarterly assessment.

(3) All Division enrolled pharmacies subject to this rule shall be required to complete an annual survey that collects claim volumes from enrolled pharmacies and other information from the previous twelve (12) month period to determine the appropriate dispensing fee reimbursement:

(a) Claims volume shall be stated by total Oregon Health Plan (OHP) covered prescriptions and claims from all payer types;

(b) Survey activities shall be conducted by either the Division or its contractor and must be completed and returned by pharmacies within fourteen (14) days of receipt;

(d) Pharmacies other than IHS or Tribal pharmacies, that fail to respond to the survey or do not include the letter of attestation shall default to the highest volume tier;

(e) Once a volume-based tier is established for a calendar year, the pharmacy’s dispensing fee shall remain in that tier until the next annual claims volume survey is conducted;

(f) Newly enrolled 340B pharmacies shall be reimbursed at a rate of $20.86 per claim. All other pharmacies shall be defaulted to the highest volume tier until the next claims volume survey is conducted.

[Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 137-2024, amend filed 11/20/2024, effective 12/01/2024
DMAP 50-2017, amend filed 12/05/2017, effective 01/01/2018
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12
DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05
OMAP 21-2004, f. 3-15-04, cert. ef. 4-15-04
OMAP 19-2004(Temp), f. & cert. ef. 3-15-04 thru 4-14-04
OMAP 7-2004, f. 2-13-04, cert. ef. 3-15-04
OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 32-2003(Temp), f. & cert. ef. 4-15-03 thru 9-15-03
OMAP 60-2001, f. & cert. ef. 12-11-01
OMAP 50-2001(Temp), f. 9-28-01, cert. ef. 10-1-01 thru 3-1-02
OMAP 1-1999, f. & cert. ef. 2-1-99
OMAP 22-1998, f. & cert. ef. 7-15-98
OMAP 5-1998(Temp), f. & cert. ef. 2-11-98 thru 7-15-98
HR 12-1994, f. 2-25-94, cert. ef. 2-27-94
HR 21-1993(Temp), f. & cert. ef. 9-1-93
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90
HR 20-1990, f. & cert. ef. 7-9-90, Renumbered from 461-016-0260
AFS 79-1989, f. & cert. ef. 12-21-89
AFS 63-1989(Temp), f. & cert. ef. 10-17-89
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0101
AFS 64-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 41-1988(Temp), f. 6-13-88, cert. ef. 7-1-88
AFS 50-1987, f. 10-20-87, cert. ef. 11-1-87
AFS 28-1987(Temp), f. & cert. ef. 7-14-87
AFS 12-1987, f. 3-3-87, cert. ef. 4-1-87
AFS 52-1986, f. & cert. ef. 7-2-86
AFS 36-1986, f. 4-15-86, cert. ef. 6-1-86
AFS 13-1986(Temp), f. 2-5-86, cert. ef. 3-1-86
AFS 66-1985, f. 11-5-85, cert. ef. 12-1-85
AFS 54-1985(Temp), f. 9-23-85, cert. ef. 10-1-85
AFS 1-1985, f. & cert. ef. 1-3-85
AFS 41-1984(Temp), f. 9-24-84, cert. ef. 10-1-84
AFS 56-1983, f. 11-17-83, cert. ef. 12-1-83
AFS 51-1983(Temp), f. 9-30-83, cert. ef. 10-1-83

Or. Admin. R. 410-121-0185 Pharmacy Based Immunization Delivery

(1) Pursuant to ORS 689.645 and the Board of Pharmacy administrative rule OAR 855-115-0305, pharmacists may prescribe and administer vaccines to persons ;

(a) Who are seven (7) years of age or older;

(b) If authorized by the Governor or the Director of the Oregon Department of Emergency Management under ORS 433.441 or the Public Health Director under ORS 433.443 or 433.444, to a person three (3) years of age or older; or

(2) To receive reimbursement for vaccine administration and serum for adults (ages 19 and older), the pharmacy may bill either:

(a) Through Point-of-Sale (POS) using the appropriate National Drug Code (NDC) for the serum, and the administration fee shall automatically be applied equivalent to Current Procedural Terminology (CPT) codes 90470-90474 ; or

(b) Bill on a CMS-1500, OHP 505, or Provider Web Portal professional claim using the appropriate immunization CPT code for the serum; or

(3) If billing as a professional claim, the pharmacy must include:

(a) A primary diagnosis to the highest degree of specificity;

(b) The appropriate CPT code for the serum, code ranges 90476-90749; and

(4) Vaccines for Children (VFC) is a federal program that provides vaccine serums at no cost to providers for patients under age 19. All vaccines for this age group and for conditions covered by the VFC program must be obtained through the VFC program. For information about the VFC program or to enroll as a VFC provider, contact the Public Health Immunization Program. The Oregon VFC program website is located at http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/vfc/Pages/index.aspx.

(5) The Division shall reimburse only for the administration, not the serum, of vaccines available for free through the VFC program. For a list of vaccines provided through the VFC program, see the current Oregon Immunization Program State-Supplied Vaccine Billing Codes table available at https://www.oregon.gov/oha/ph/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/Documents/NewCPTcodes.pdf

(6) To receive reimbursement for vaccine administration to a child age seven (7) through eighteen (18), the pharmacy must:

(a) Be enrolled as a pharmacy provider in the VFC program;

(b) Bill on a CMS-1500, OHP 505, or Provider Web Portal professional claim;

(d) Include the appropriate modifier –SL or -26;

(7) For detailed information on billing for the VFC Program, refer to Medical Surgical Services OAR 410-130-0255.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 145-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 11-2018, amend filed 03/02/2018, effective 03/02/2018
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10
DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 9-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 7-2002, f. & cert. ef. 4-1-02
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01

Or. Admin. R. 410-121-0190 Medication Therapy Management Services and Clozapine Therapy Monitoring

(1) Clozapine monitoring protocol requires enhanced record keeping and reporting to the drug manufacturer’s registry in order to dispense the medication. Dispensing pharmacy must meet all drug manufacturers requirements including data reporting.

(2) Clozapine monitoring includes documentation of client’s diagnosis, dosage, dosage changes, appropriate laboratory reports (e.g. white blood cell counts), evaluation intervals, and submission of appropriate information to drug manufacturer to allow dispensing of medication;

(3) Clozapine monitoring is to be billed using appropriate Medication Therapy Management Services (MTMS) Current Procedural Terminology (CPT) code with the modifier TC appended. This is limited to no more than 5 units in 30 day time period per client, including the 30 day period from the date of discontinuation of clozapine therapy;

(4) Clozapine monitoring must be billed by a pharmacy;

(5) MTMS rendered outside of clozapine management must be performed by a licensed pharmacist and must be billed to appropriately reflect the performing provider. These encounters must be billed using the appropriate MTMS CPT code without the TC modifier.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 26-2013, f. & cert. ef. 6-25-13
DMAP 59-2012(Temp), f. 12-27-12, cert. ef. 12-28-12 thru 6-25-13
DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12
OMAP 61-2005, f. 11-29-05, cert. ef. 12-1-05
OMAP 9-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03
OMAP 20-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 45-2002, f. & cert. ef. 10-1-02
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 17-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 6-1995, f. 3-31-95, cert. ef. 4-1-95
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94

Or. Admin. R. 410-121-0200 Billing Forms

Guidelines for using the Prescription Drug Invoice 1.2 Universal Claim Form.

(1) When a paper claim form is needed, this form is used to bill for all pharmacy services, home blood glucose monitors, and related diabetic supplies. These services must be billed with a National Drug Code (NDC).

(2) The provider may bill on the form when a valid Medical Care Identification has been presented (Refer to OAR 410-120-1140 Verification of Eligibility).

(3) All completed 1.2 Universal Claim Forms must be mailed to the Health Systems Division (Division).

(4) All other durable medical equipment and certain Enteral/Parenteral Nutrition and IV Services must be billed on the CMS-1500, using the billing instructions found in the Division’s Durable Medical Equipment and Medical Supplies administrative rules (division 122) and Supplemental Information, and the Division’s Home Enteral/Parenteral Nutrition and IV Services Administrative rules (division 148) and Supplemental Information. These services are billed with HCPCS procedure codes.

NOTE: Publications referenced are available from the agency.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 11-2018, amend filed 03/02/2018, effective 03/02/2018
DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03
OMAP 20-2003, f. 3-26-03, cert. ef. 4-1-03
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-121-0220 Instructions for Completion of the Prescription Drug Invoice

(1) The 1.2 Universal Claim Form is the required billing form for pharmacies billing on a paper claim. Use the standard instructions for completion of the 1.2 Universal Claim Form.

(2) Enter all applicable information for billing of prescription drug claims for clients on the Oregon Health Plan.

History

Statutory/Other Authority: ORS 413.042, 414.034 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 11-2018, amend filed 03/02/2018, effective 03/02/2018
OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 23-1995, f. 12-29-95, cert. ef. 1-1-96
HR 2-1995, f. & cert. ef. 2-1-95
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 14-1993, f. & cert. ef. 7-2-93
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0280
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89

Or. Admin. R. 410-121-0280 Billing Quantities, Metric Quantities and Package Sizes

(1) Use the actual metric quantity dispensed when billing (up to four decimal places).

(2) Use the following units when billing products:

(a) Solid substances (e.g., powders, creams, ointments, etc.), bill per Gram;

(b) Solid substances that are reconstituted with a liquid (e.g., dry powder ampules and vials) such as antibiotic vials or piggybacks must be billed in metric quantity of one each;

(c) Tablets, capsules, suppositories, lozenges, packets; bill per each unit. Oral contraceptives are to be billed per each tablet;

(d) Injectables that are prepackaged syringe — (e.g., tubex, carpujects), bill per ml.;

(e) Prepackaged medications and unit doses must be billed per unit (tablet or capsule). Unit dose liquids are to be billed by ml.;

(f) Fractional units: Bill exact metric decimal quantities dispensed.

History

Statutory/Other Authority: ORS 413.042, 414.034 & 414.065
Statutes/Other Implemented: ORS 414.065
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0320
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89

Or. Admin. R. 410-121-0300 CMS Federal Upper Limits for Drug Payments

(1) The Centers for Medicare and Medicaid Services (CMS) Federal Upper Limits for Drug Payments listing of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and 1927(e) of the Act as amended by OBRA 1993 and the DRA 2005.

(2) Payments for multiple source drugs must not exceed, in the aggregate, payment levels determined by applying to each drug entity a reasonable dispensing fee (established by the State and specified in the State Plan), plus an amount based on the limit per unit. CMS has determined the amount based on the limit per unit to be equal to 250 percent of the Average Manufacturer’s Price (AMP). CMS will post the AMP to a Website available to the public on a quarterly basis.

(3) The FUL drug listing is published in the State Medicaid Manual, Part 6, Payment for Services, Addendum A. The most current Transmittals and subsequent changes are posted to the CMS website https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 37-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 50-2006, f. 12-28-06, cert. ef. 1-1-07
OMAP 13-2006, f. 5-26-06, cert. ef. 6-1-06
OMAP 8-2006(Temp), f. 3-29-06, cert. ef. 4-1-06 thru 9-15-06
OMAP 68-2005, f. 12-21-05, cert. ef. 1-1-06
OMAP 59-2005(Temp), f. 11-8-05, cert. ef. 11-12-05 thru 5-1-06
OMAP 56-2005, f. 10-25-05, cert. ef. 11-1-05
OMAP 29-2005, f. & cert. ef. 6-6-05
OMAP 23-2005(Temp), f. & cert. ef. 4-1-05 thru 9-1-05
OMAP 2-2005, f. 1-31-05, cert. ef. 2-1-05
OMAP 93-2004(Temp), f. & cert. ef. 12-10-04 thru 5-15-05
OMAP 43-2004, f. 6-24-04 cert. ef. 7-1-04
OMAP 32-2004(Temp), f. & cert. ef. 5-14-04 thru 10-15-04
OMAP 2-2004, f. 1-23-04, cert. ef. 2-1-04
OMAP 83-2003(Temp), f. 11-25-03, cert. ef. 12-1-03 thru 4-15-04
OMAP 75-2003, f. & cert. ef. 10-1-03
OMAP 54-2003(Temp), f. & cert. ef. 8-15-03 thru 1-15-03
OMAP 51-2003, f. & cert. ef. 8-5-03
OMAP 41-2003, f. & cert. ef. 5-29-03
OMAP 11-2003(Temp), f. 2-28-03, cert. ef. 3-1-03 thru 8-15-03
OMAP 10-2003, f. 2-28-03, cert. ef. 3-1-03
OMAP 71-2002(Temp), f. & cert. ef. 12-1-02 thru 5-15-03
OMAP 29-2002(Temp), f. 7-15-02, cert. ef. 8-1-02 thru 1-1-03
OMAP 19-2002(Temp), f. & cert. ef. 4-22-02 thru 9-15-02
OMAP 5-2002(Temp), f. & cert. ef. 3-5-02 thru 6-15-02
OMAP 3-2002(Temp), f. & cert. ef. 2-15-02 thru 6-15-02
OMAP 67-2001(Temp), f. 12-28-01, cert. ef. 1-1-02 thru 5-15-02
OMAP 58-2001, f. 11-30-01, cert. ef. 12-1-01
OMAP 51-2001(Temp) f. 9-28-01, cert. ef. 10-1-01 thru 3-15-01
OMAP 26-2001(Temp), f. & cert. ef. 6-6-01 thru 1-2-02
OMAP 23-2001(Temp), f. & cert. ef. 4-16-01 thru 8-1-01
OMAP 18-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 2-2001(Temp), f. 2-14-01, cert. ef. 2-15-01 thru 7-1-01
OMAP 1-2001(Temp), f. & cert. ef. 2-1-01 thru 6-1-01
OMAP 42-2000(Temp), f. & cert. ef. 12-15-00 thru 5-1-01
OMAP 5-1999, f. & cert. ef. 2-26-99
OMAP 43-1998(Temp), f. & cert. ef. 11-20-98 thru 5-1-99
OMAP 2-1998, f. 1-30-98, cert. ef. 2-1-98
HR 27-1997, f. & cert. ef. 12-1-97
HR 22-1997, f. & cert. ef. 10-1-97
HR 23-1995, f. 12-29-95, cert. ef. 1-1-96
HR 14-1995, f. 6-29-95, cert. ef. 7-1-95
HR 6-1995, f. 3-31-95, cert. ef. 4-1-95
HR 2-1995, f. & cert. ef. 2-1-95
HR 25-1994, f. & cert. ef. 7-1-94
HR 14-1994, f. & cert. ef. 3-1-94
HR 25-1993(Temp), f. & cert. ef. 10-1-93
HR 20-1993, f. & cert. ef. 9-1-93
HR 15-1993(Temp), f. & cert. ef. 7-2-93
HR 11-1993, f. 4-22-93, cert. ef. 4-26-93
HR 8-1993(Temp), f. & cert. ef. 4-1-93
HR 5-1993(Temp), f. 3-10-93, cert. ef. 3-22-93
HR 3-1993, f. & cert. ef. 2-22-93
HR 1-1993(Temp), f. & cert. ef. 1-25-93
HR 35-1992(Temp), f. & cert. ef. 12-1-92
HR 28-1992, f. & cert. ef. 9-1-92
HR 13-1992, f. & cert. ef. 6-1-92
HR 37-1991, f. & cert. ef. 9-16-91
HR 10-1991, f. & cert. ef. 2-19-91
HR 45-1990, f. & cert. ef. 12-28-90
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90
HR 20-1990, f. & cert. ef. 7-9-90
HR 13-1990, f. & cert. ef. 4-20-90, Renumbered from 461-016-0330
HR 3-1990(Temp), f. & cert. ef. 2-23-90
AFS 79-1989, f. & cert. ef. 12-21-89
AFS 63-1989(Temp), f. & cert. ef. 10-17-89
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89

Or. Admin. R. 410-121-0420 DESI Less-Than-Effective Drug List

(1) An October 23, 1981 ruling by District of Columbia Federal Court directed the Department of Health and Human Services to stop reimbursement, effective October 30, 1981, under Medicaid and Medicare Part B for all DESI less-than-effective drugs which have reached the Federal Drug Administration Notice-of-Opportunity-for-Hearing stage.

(2) In accordance with Section 1903(i)(5) of the Social Security Act, federal funds participation (FFP) is not available for drugs deemed Less Than Effective (LTE) or Identical, Related of Similar (IRS) drugs for which the Food and Drug Administration (FDA) issued a Notice of Opportunity for a Hearing (NOOH) for all labeled indications. These drugs are also termed Drug Efficacy Study Implementation (DESI) drugs. Division does not reimburse for drugs designated as less than effective or drugs identical, related, or similar to a DESI drug.

(3) A current list of DESI LTE/IRS drugs is available at https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/medicaid-drug-rebate-program-data/index.html. DESI drugs are identified by Covered outpatient Drug (COD) Status of 5 or 6.

(4) The US Food & Drug Administration (FDA) has the responsibility of determining the DESI status of a drug product.

History

Statutory/Other Authority: ORS 413.042 & 414.325
Statutes/Other Implemented: ORS 414.065
DMAP 96-2022, amend filed 12/28/2022, effective 01/01/2023
DMAP 38-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 20-1991, f. & cert. ef. 4-16-91
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0390
HR 17-1990(Temp), f. 6-29-90, cert. ef. 7-1-90
AFS 79-1989, f. & cert. ef. 12-21-89
AFS 64-1989(Temp), f. 10-24-89, cert. ef. 11-15-89
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89

Or. Admin. R. 410-121-0580 Oregon Medicaid and Pharmaceutical Manufacturers’ Dispute Resolution Procedures

(1) Within 60 days after the end of each calendar quarter, the Division of Medical Assistance Programs (Division) shall report the number of units dispensed for each drug National Drug Code (NDC) for which payment was made to the manufacturer of said product. Utilization reports to manufacturers shall follow this schedule:

(a) The period from January 1 through March 31 will be Quarter 1. Quarter 1 invoices shall be due by May 30 of that same year;

(b) The period from April 1 through June 30 will be Quarter 2. Quarter 2 invoices shall be due by August 29 of that same year;

(c) The period from July 1 through September 30 will be Quarter 3. Quarter 3 invoices shall be due by November 29 of that same year;

(d) The period from October 1 through December 31 will be Quarter 4. Quarter 4 invoices shall be due by February 29 of the following year.

(2) A manufacturer must make payment within 30 days of receipt of utilization reports, i.e., rebate invoice. Using eight days as reasonable time for reports to reach the manufacturer, payment of the invoiced amount is due per the following schedule:

(a) Rebate payment for Quarter 1 shall be due by July 7 of that same year;

(b) Rebate payment for Quarter 2 shall be due by October 7 of that same year;

(d) Rebate payment for Quarter 4 shall be due by April 6 of the following year.

(3) Division considers any failure to make timely payment in full of the amount due to be a dispute. Timely is defined by Division as 38 days after the postmarked date of the invoice.

(4) If a manufacturer does not indicate in writing, by specific NDC number(s), the reason(s) for non-payment in full, a letter asking for clarification will be sent and interest will accrue as set forth in the Rebate Agreement, Section V, Dispute Resolution, beginning 38 days after the postmarked date of each invoice.

(5) Utilization/unit disputes shall be handled by a careful examination of paid claims data to determine the reasonableness of the reported units of products provided to Oregon recipients. If it is determined that the manufacturer is in error a letter notifying the manufacturer of the completed review and findings will be mailed to the manufacturer and interest will accrue as set forth in the Rebate Agreement, Section V, Dispute Resolution.

(6) If a manufacturer determines that incorrect information was sent to the Centers for Medicare and Medicaid Services (CMS), the manufacturer must still make payment in full to Oregon Medicaid for the invoiced rebate amount. Oregon Medicaid will credit the manufacturer's account through CMS’s prior period adjustment process.

(7) Interest will accrue as set forth in the Rebate Agreement, Section V, Dispute Resolution, on the 31st day after a manufacturer receives information from Division on the number of units paid by NDC number (i.e., rebate invoice).

(8) Manufacturer requests for audit information by product and zip codes will be acknowledged by Division in letter form. Each letter will include a Division Audit Request Form and instructions to the manufacturer on how to complete the form. The letter will also include a standard explanation of the audit process.

(9) Days referred to in this process shall be considered calendar days.

(10) Efforts should be made through an informal rebate resolution process as outlined in this rule before a hearing will be scheduled. Hearings will follow OAR 410-120-0760 through 410-120-1060 and be held in Marion County, OR.

(11) Oregon Medicaid will notify CMS of all disputing manufacturers in writing.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
HR 21-1992, f. 7-31-92, cert. ef. 8-1-92

Or. Admin. R. 410-121-0625 Items Covered in the All-Inclusive Rate for Nursing Facilities

(1) The all-inclusive rate for nursing facilities includes but is not limited to various drug products and OTC items. Division requires that nursing facilities be billed for these items.

(2) The all-inclusive list is available for downloading in the Division of Medical Assistance Programs Web page on the Oregon Health Authority’s website.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04
OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0920
OMAP 1-1999, f. & cert. ef. 2-1-99
HR 20-1994, f. 4-29-94, cert. ef. 5-1-94
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Division 122 DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS)

Or. Admin. R. 410-122-0010 Definitions

In addition to the definitions in OAR 410-120-0000, the following definitions in these rules apply:

(1) “Activities of Daily Living (ADL's)” means activities related to personal care including, but not limited to, tasks such as eating, toileting, grooming, dressing, and bathing that are necessary to maintain or improve the client's health.

(2) “Acquisition Cost” has the meaning given to the term in OAR Chapter 410 Division 120.

(3) "Buy-up" means a situation in which a client wants to upgrade to a higher level of service than he or she is eligible for; e.g., a heavy-duty walker instead of a standard walker.

(4) “Complex Rehabilitation Technology” has the meaning given in 2025 Oregon Laws Chapter 258, Section 2.

(5) “Consecutive Months” means any period of continuous use where no more than a 60-day break occurs.

(6) “Division” means the Health Systems Division within the Authority. The Division is responsible for coordinating the medical assistance programs within the State of Oregon including the Oregon Health Plan (OHP) Medicaid demonstration, the State Children's Health Insurance Program (SCHIP-Title XXI), and several other programs.

(7) “DMEPOS” is an acronym for durable medical equipment, prosthetics, orthotics, and supplies.

(8) “Durable Medical Equipment” means equipment and appliances that are primarily and customarily used to serve a medical purpose, generally are not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, can be reusable or removable, and is appropriate for use in any non-institutional setting in which normal life activities take place. Some examples include wheelchairs, crutches, and hospital beds.

(9) "EPSDT" means the Early and Periodic Screening, Diagnostic and Treatment program which provides comprehensive and preventive health care services to OHP clients in accordance with federal regulations and as defined in OAR Chapter 410 Division 151.

(10) “EPSDT Beneficiary” has the meaning given that term in OAR Chapter 410 Division 120 and OAR Chapter 410 Division 151.

(11) “Healthcare Professionals” has the meaning given that term in OAR Chapter 410 Division 120.

(12) “Home” for purposes of purchase, rental, and repair of durable medical equipment (DME) means a place of permanent residence such as an assisted living facility, 24-hour residential care facility, adult foster home, child foster home, or a private home. This does not include hospitals, nursing facilities, intermediate care facilities for individuals with intellectual disabilities, any setting that exists primarily for the purpose of providing medical/nursing care, or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Separate payment may not be made to DME providers for equipment and medical supplies provided to a client when the cost of such items is already included in the capitated (per diem) rate paid to a facility or organization.

(13) “Instrumental activities of daily living (IADLs)” means activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.

(14) “Licensed Practitioner of the Healing Arts (LPHA)” means a physician or other practitioner licensed in the State of Oregon who is authorized within the scope of the LPHA’s practice, as defined under state law, to diagnose and treat individuals with physical or mental disabilities or psychosocial, emotional, and behavioral disorders.

(15) “Lifetime Need” means 99 months or more.

(16) “Manufacturer Part Number (MPN)” means:

(a) Each manufacturer provides an MPN to identify that manufacturer's part. It is a specification used by the manufacturer to store a part in an illustrated part catalog (graphics and text).

(b) An MPN uniquely identifies a part when used together with manufacturer code (external manufacturer), which is the own name used by the manufacturer and not the manufacturer name provided by other.

(17) “Medical Records” means the practitioner’s office records, hospital records, nursing facility records, home health agency records, records from other healthcare professionals, and diagnostic and test reports. This documentation must be made available to the Health Systems Division (Division) upon request.

(18) “Medical Supplies” means health care related items that are consumable or disposable or cannot withstand repeated use by more than one individual, that are required to address an individual medical disability, illness, or injury. Examples of medical supplies include diapers, syringes, gauze bandages, and tubing.

(19) “Medically Appropriate” has the meaning given that term in OAR Chapter 410 Division 120 for adult beneficiaries and OAR Chapter 410 Division 151 for EPSDT beneficiaries.

(20) “Medically Necessary” has the meaning given that term in OAR Chapter 410 Division 120 for adult beneficiaries and OAR Chapter 410 Division 151 for EPSDT beneficiaries.

(21) “Mobility-related Activities of Daily Living (MRADL's)” means personal care activities including, but not limited to, tasks such as toileting, feeding, dressing, grooming, and bathing in customary locations.

(22) “Morbidity” means a diseased state, often used in the context of a "morbidity rate" (i.e., the rate of disease or proportion of diseased people in a population). In common clinical usage, any disease state including diagnosis and complications is referred to as morbidity.

(23) “Morbidity Rate” means the rate of illness in a population. The number of people ill during a time period is divided by the number of people in the total population.

(24) “Practitioner” means an individual licensed pursuant to federal and state law to engage in the provision of health care services within the scope of the practitioner's license and certification.  For ordering and provision of durable medical equipment, prosthetics, orthotics and medical suppliers this includes both physicians and non-physician practitioners (i.e., physician associate, nurse practitioners, and certified nurse specialists) as defined in section 1861 of the Social Security Act).

(25) “Prosthetic and Orthotic Devices” means devices that replace all or part of an internal body organ, including ostomy bags and supplies directly related to ostomy care and replacement of such devices and supplies. Prosthetic and orthotic devices also include leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the client's physical condition.

(26) “Purchase price” means:

(a) Delivery;

(b) Assembly;

(d) Training in the use of the equipment or supply.

(27) “Rental fees” means:

(a) Delivery;

(b) Training in the use of the equipment;

(d) Routine service, maintenance, and repair; and

(e) Moving equipment to a new residence, if coverage is to continue.

(28) “Technician” means a DMEPOS provider staff professionally trained through product or vendor-based training, technical school training (e.g., electronics), or through apprenticeship programs with on-the-job training.

(29) “The Division Maximum Allowable Rate” means the maximum amount paid by the Division for a service.

(30) “Young Adults with Special Health Care Needs (YSHCN)” has the meaning given that term in OAR Chapter 410 Division 120 and OAR Chapter 410 Division 200.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 5-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 32-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 54-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 44-2004, f. & cert. ef. 7-1-04

Or. Admin. R. 410-122-0020 Orders

(1) The purchase, rental, or modifications of durable medical equipment and the purchase of supplies must have an order from the prescribing practitioner prior to dispensing items to a client.

(2) For any durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), a provider must have a written order signed and dated by the prescribing practitioner prior to submitting a claim to the Division.

(3) A provider may dispense some items based on a verbal order from the prescribing practitioner, except those items requiring a written order prior to delivery or as specified in a particular rule:

(a) A provider must maintain documentation of the verbal order and this documentation must be available to the Division upon request;

(b) The verbal order must include all of the following elements:

(A) Client’s name;

(B) Practitioner’s name;

(D) Start date of the order;

(E) Primary ICD-10 diagnosis code for the equipment/supplies requested.

(c) For items that are dispensed based on a verbal order, the provider must obtain a written order that meets the requirements outlined below for written orders.

(4) When specified in rule, a nurse practitioner or clinical nurse specialist may provide the dispensing order and sign the detailed written order only when the following are met:

(a) They are treating the client for the condition for which the item is needed; and

(b) They are practicing independently of a physician; and

(5) When specified in rule, a physician associate may provide the dispensing order and sign the detailed written order only when the following are met:

(a) They are treating the client for the condition for which the item is needed; and

(b) They are practicing under the supervision of a Doctor of Medicine or Doctor of Osteopathy; and

(6) The DMEPOS provider must have on file a written order, information from the prescribing practitioner concerning the client’s diagnosis and medical condition, and any additional information required in a specific rule.

(7) The Division accepts any of the following forms of orders: a photocopy, facsimile image, electronically maintained or original “pen and ink” document:

(a) An electronically maintained document is one that has been created, modified, and stored via electronic means such as commercially available software packages and servers;

(b) The provider shall ensure the authenticity and validity of a facsimile image, electronically maintained or photocopied order;

(d) The written order may serve as the order to dispense the item if the written order is obtained before the item is dispensed.

(8) A written order must be legible and contain the following elements:

(a) Client’s name; and

(b) Detailed description of the item that can either be a general description (e.g., lightweight wheelchair base) or a brand name/model number including medically appropriate options or additional features; and

(c) The detailed description of the item may be completed by someone other than the practitioner. However, the prescribing practitioner must review the detailed description and personally indicate agreement by his signature and the date that the order is signed:

(A) Practitioners shall sign for services they order;

(B) This signature must be handwritten or electronic, and it must be in the client’s medical record;

(d) Primary ICD-10 diagnosis code for the equipment and supplies requested; and

(e) Quantity to be dispensed, if applicable; and

(f) Order date; and

(g) Treating practitioner’s name; and

(h) Treating practitioner’s signature:

(A) This signature must be handwritten or electronic, and it must be in the client’s medical record;

(B) The ordering/treating practitioner shall ensure the authenticity of the signature; and

(9) The DMEPOS provider shall obtain as much documentation from the client’s medical record as necessary for assurance that the Division coverage criteria for an item is met.

(10) Certain items require one or more of the following additional elements in the written order:

(a) For accessories or supplies that will be provided on a periodic basis:

(A) Quantity used;

(B) Specific frequency of change or use. “As needed” or “prn” orders are not acceptable;

(D) Length of need. For example, an order for surgical dressings might specify one “4 x 4” hydrocolloid dressing that is changed one to two times per week for one month or until the ulcer heals.

(b) For orthoses, if a custom-fabricated orthosis is ordered by the practitioner, this must be clearly indicated on the written order;

(A) If the coverage criteria in a rule specifies length of need; or

(B) If the order is for a rental item.

(d) Any other medical documentation required by rule.

(11) Repairs, labor for repairs, parts for durable medical equipment (DME) repairs, and replacement parts for DME (e.g., batteries) do not require a written order.

(12) A new order is required:

(a) When required by Medicare for a Medicare covered service;

(b) When there is a change in the original order for an item (e.g., quantity);

(d) When indicated by the prescribing practitioner:

(A) A new order is required when an item is being replaced because the item is worn or the client’s condition has changed;

(B) The provider’s records shall include client-specific information regarding the need for the replacement item;

(D) A new order is required before replacing lost, stolen, or irreparably damaged items to reaffirm the medical appropriateness of the item.

(e) When there is a change in a DMEPOS provider or in cases where two or more providers merge, the recipient provider shall make all reasonable attempts to secure copies of all written orders from the transferring provider. This document shall be kept on file by the recipient provider and made available upon request by the Division;

(f) On a regular basis (even if there is no change in the order) when it is so specified in the documentation section of a particular rule.

(13) A provider shall maintain and provide legible copies of facsimile images and electronic transmissions of orders.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
DMAP 6-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 36-2003, f. & cert. ef. 5-1-03
OMAP 72-2002(Temp), f. & cert. ef. 12-24-02 thru 5-15-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
HR 17-1996, f. & cert. ef. 8-1-96
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 13-1991, f. & cert. ef. 3-1-91, Renumbered from 461-024-0004
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 49-1987, f. 10-16-87, ef. 11-1-87
AFS 20-1983, f. 5-5-83, ef. 6-1-83
AFS 52-1982, f. & ef. 5-1-82
AFS 41-1982, f. & ef. 4-29-82

Or. Admin. R. 410-122-0040 Prior Authorization

(1) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers shall obtain prior authorization (PA) for Healthcare Common Procedure Coding System (HCPCS) Level II codes as specified in rule, unless otherwise noted.

(a) Providers shall request PA as follows:

(A) For Medically Fragile Children’s Unit (MFCU) clients, from the Department of Human Services (Department) MFCU;

(B) For clients enrolled in a Coordinated Care Organization (CCO), from the CCO;

(D) For all other clients, from the Health Systems Division.

(b) For DMEPOS provided after normal working hours, providers must submit PA requests within five working days from the initiation of service.

(2) Effective January 1, 2026, the Division shall provide notice of determination no later than 72 hours following receipt of PA requests for costs to repair complex rehabilitation technology as defined in Section 2 of Enrolled SB 549 (2025). The 72-hour period of time shall be determined by the time and date stamp on the receipt of request.

History

Statutory/Other Authority: ORS 414.065 & SB 549 (2025)
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 58-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 61-2015, f. 10-29-15, cert. ef. 11-1-15
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 26-2004, f. 4-15-04 cert. ef. 5-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 20-2004(Temp), f. & cert. ef. 3-15-04 thru 4-30-04
OMAP 6-2004, f. 2-10-04 cert. ef. 3-15-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91, Renumbered from 461-024-0010
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 6-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 40-1984, f. 9-18-84, ef. 10-1-84
AFS 22-1984(Temp), f. & ef. 5-1-84
AFS 14-1984(Temp), f. & ef. 4-2-84
AFS 3-1982, f. 1-20-82, ef. 2-1-82

Or. Admin. R. 410-122-0080 Conditions of Coverage, Limitations, and Restrictions

(1) For EPSDT beneficiaries (as defined in OAR 410-151-0001) and clients in the Young Adults with Special Health Care Needs or “YSHCN” program (as defined in OAR 410-200-0455): The EPSDT program covers all medically necessary and medically appropriate services needed to correct or ameliorate health conditions, or to improve the client’s ability to grow, develop, or participate in school, regardless of placement on or inclusion in the Prioritized List of Health Services. Coverage for medical equipment and supplies shall not be denied without an individual review for medical necessity and medical appropriateness, as defined in OAR 410-151-0001.

(2) For clients age 21 and older: The Division may pay for durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) when the item meets all criteria in these rules, including all of the following conditions. The item:

(a) Is either approved, registered, or listed as a medical device by the Food and Drug Administration (FDA), and the item is otherwise generally considered to be safe and effective for the intended purpose. In the event of delay in FDA approval and/or registration, the Division shall review purchase options on a case-by-case basis;

(b) Is medically appropriate and medically necessary for the client, as defined in OAR 410-120-0000;

(d) Is generally not useful to an individual in the absence of medical disability, illness, or injury;

(e) Is suitable for use in a client’s home or any non-institutional setting in which normal life activities take place;

(f) Specifically for durable medical equipment, the item can withstand repeated use and can be reusable or removable;

(g) Meets the coverage criteria as specified in this division and subject to service limitations of the Division rules;

(h) Is requested in relation to a diagnosis and treatment pair that is above the funding line and consistent with treatment guidelines on the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List of Health Services or List) or qualify for coverage under OAR 410-141-3820(11);

(i) Is included in the Oregon Health Plan (OHP) client’s benefit package of covered services;

(j) Is the least costly, medically appropriate item that meets the medical needs of the client;

(k) Coverage is not restricted to items covered by the Medicare program.

(3) Conditions for Medicare-Medicaid Services:

(a) If Medicare is the primary payer and Medicare denies payment, an appeal to Medicare must be filed timely prior to submitting the claim to the Division for payment. If Medicare denies payment based on failure to submit a timely appeal, the Division may reduce any amount the Division determines could have been paid by Medicare;

(b) If Medicare denies payment on appeal, the Division shall apply DMEPOS coverage criteria in this rule to determine whether the item or service is covered under the OHP;

(c) Providers are not required to bill Medicare for items that are statutorily excluded and therefore not recognized as part of a covered Medicare benefit (e.g., incontinence supplies, bath equipment, adaptive car seats, standing frames). Prior authorization criteria for these services/items must still be met.

(4) The Division may not cover DMEPOS items when the item or the use of the item is:

(a) Not primarily medical in nature (e.g., personal hygiene items, sporting and fitness equipment, equipment used with the primary intent to physically restrain an individual);

(b) For personal comfort or convenience of the client or caregiver;

(d) Not therapeutic or diagnostic in nature;

(e) Used for precautionary reasons;

(f) Inappropriate for client use in the home or non-institutional setting (e.g., institutional equipment like an oscillating bed);

(g) For a purpose where the medical effectiveness is not supported by evidence-based clinical practice guidelines; or

(h) Reimbursed as part of the bundled rate in a nursing facility as described in OAR 411-070-0085 or as part of a home and community-based care waiver service or by any other public, community, or third-party resource.

(5) Codes that are identified in these rules or in fee schedules are provided as a mechanism to facilitate payment for covered items and supplies consistent with OAR 410-122-0186, but codes do not determine coverage. If prior authorization is required, the request for reimbursement shall document that prior authorization was obtained in compliance with the rules in this division.

(6) DMEPOS providers shall have documentation on file that supports coverage criteria are met.

(7) Billing records shall demonstrate that the provider has not exceeded any limitations and restrictions in the DMEPOS rules. The Division may require additional claim information from the provider consistent with program integrity review processes.

(8) Documentation described in sections (5), (6), and (7) above shall be made available to the Division upon request.

(9) The Division fee schedule provides a list of HCPCS codes that may be covered when criteria are met. Coverage may be provided for HCPCS codes that do not appear on the fee schedule with an individual medical appropriateness review as outlined in this rule.

(10) Some benefit packages do not cover equipment and supplies (see OAR 410-120-1210, Medical Assistance Benefit Packages and Delivery System).

(11) Buy-ups are prohibited. Advanced Beneficiary Notices (ABN) constitute a buy-up and is prohibited. Refer to the Division General Rules (chapter 410, division 120) for specific rules on buying up.

(12) Equipment purchased by the Division for a client becomes the property of the client.

(13) Rental charges starting with the initial date of service, regardless of payer, apply to the purchase price.

(14) A provider who supplies rented equipment shall continue furnishing the same item throughout the entire rental period, except under documented reasonable circumstances.

(15) Before renting, providers must consider purchase for long-term requirements.

(16) The Division may not pay DMEPOS providers for medical supplies separately while a client is under a home health plan of care and covered home health care services.

(17) The Division may not pay DMEPOS providers for medical supplies separately while a client is under a hospice plan of care where the supplies are included as part of the written plan of care and for which payment may otherwise be made by Medicare, the Division, or other carrier.

(18) Separate payment may not be made to DMEPOS providers for equipment and medical supplies provided to a client when the cost of the items is already included in the capitated (per diem) rate paid to a facility or organization.

(19) Certain specified medical equipment and supplies require a face-to-face examination as described in these rules consistent with federal regulations at 42 CFR 440.70. See OAR 410-122-0090 for the face-to-face requirements.

(20) Non-contiguous out-of-state DMEPOS providers may seek Medicaid payment only under the following circumstances:

(a) Medicare/Medicaid clients:

(A) For Medicare covered services and then only Medicaid payment of a client’s Medicare cost-sharing expenses for DMEPOS services when all of the following criteria are met:

(i) Client is a qualified Medicare beneficiary (QMB);

(ii) Service is covered by Medicare;

(iii) Medicare has paid on the specific code. Prior authorization is not required.

(B) Services not covered by Medicare:

(i) Only when the service or item is not available in the State of Oregon, and this is clearly substantiated by supporting documentation from the prescribing practitioner and maintained in the DMEPOS provider’s records;

(ii) Some examples of services not reimbursable to a non-contiguous out-of-state provider include but are not limited to incontinence supplies, grab bars;

(iii) Services billed must be covered under the OHP;

(iv) Services provided and billed to the Division shall be in accordance with all applicable Division rules.

(b) Medicaid-only clients:

(A) For a specific Oregon Medicaid client who is temporarily outside Oregon and only when the prescribing practitioner has documented that a delay in service may cause client harm;

(B) For foster care or subsidized adoption children placed out of state;

(C) Only when the service or item is not available in the State of Oregon, and this is clearly substantiated by supporting documentation from the prescribing practitioner and maintained in the DMEPOS provider’s records;

(D) Services billed must be covered under the OHP;

(E) Services provided and billed to the Division shall be in accordance with all applicable Division rules.

(21) An individual medical appropriateness review shall be conducted by the Division or CCO on requests for any DMEPOS item, related supplies, or services that are not already identified as covered by the Division in these rules or the Division fee schedule:

(a) The DME supplier must submit clinical documentation from the prescribing practitioner that is client-specific and demonstrates there is no equally effective, less costly covered item or service that meets the client’s medical needs;

(b) The client’s prescribing practitioner must certify that the less costly alternatives have been tried and failed or could be reasonably expected to fail or is inappropriate for the client;

(c) Documentation must support that the requested item or service is medically appropriate and medically necessary as defined in OAR Chapter 410 Division 120 for adult beneficiaries and OAR Chapter 410 Division 151 for EPSDT beneficiaries. An EPSDT beneficiary is an individual under the age of 21 who is covered by the Oregon Health Plan (OHP) or an individual in the Young Adults with Special Health Care Needs (YSHCN) program as defined in OAR 410-200-0455;

(d) Requests under this section for clients enrolled in CCOs shall be directed to the CCO in which the client is enrolled, in accordance with OAR 410-122-0040(2).

(22) See General Rules OAR 410-120-1200 Excluded Services and Limitations for more information on general scope of coverage and limitations.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 126-2024, minor correction filed 10/04/2024, effective 10/04/2024
DMAP 38-2024, minor correction filed 01/25/2024, effective 01/25/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 87-2014, f. 12-31-14, cert. ef. 1-1-15
DMAP 3-2011, f. 3-23-11, cert. ef. 3-25-11
DMAP 29-2010(Temp), f. & cert. ef. 10-13-10 thru 3-25-11
DMAP 28-2010(Temp), f. & cert. ef. 10-7-10 thru 3-25-11
DMAP 26-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 46-2004, f. 7-22-04, cert. ef. 8-1-04
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 26-1994, f. & cert. ef. 7-1-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 6-1991, f. & cert. ef. 1-18-91, Renumbered from 461-024-0020
HR 24-1990(Temp), f. & cert. ef. 7-27-90
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 6-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 3-1982, f. 1-20-82, ef. 2-1-82

Or. Admin. R. 410-122-0090 Face-to-Face Encounter Requirements (for Fee-For-Service Clients)

(1) For initial ordering of DME items identified in section (9) of this rule and for those DME items identified as requiring a face-to-face visit in Division 122 rules, an in-person or telehealth face-to-face encounter that is related to the primary reason the client requires the medical equipment or supplies must occur no more than six (6) months prior to the start of services.

(2) Telehealth encounters used to satisfy the face-to-face encounter requirement for a DMEPOS item must meet the requirements outlined in the Prioritized List of Health Services Telehealth, Teleconsultations, and Online/Telephonic Services Ancillary Guideline Note.

(3) The face-to-face encounter shall be conducted and documented by one of the following practitioners:

(a) A physician;

(b) A nurse practitioner or clinical nurse specialist, as authorized by State law;

(d) A licensed practitioner of the healing arts acting within the scope of practice authorized under State law;

(4) The practitioner responsible for ordering the services must document the face-to-face encounter and clinical findings supporting that the client was evaluated or treated for a condition that supports the need for the DME items ordered within six months prior to completing the written order;

(5) If a dually eligible client is evaluated for medical equipment or supplies under Medicare and transitions to Medicaid, the Medicare face-to-face encounter documentation shall meet the Medicaid face-to-face requirement.

(6) The DME supplier shall maintain and provide documentation of the qualifying face-to-face encounter, written order/prescription, and the supporting documentation when the item requires prior authorization or at the Division’s request.

(7) The supporting documentation shall include subjective and objective client-specific information used for diagnosing, treating, and managing a clinical condition for which the DMEPOS is ordered.

(8) The DME supplier shall have documentation on file that supports all coverage criteria in the DMEPOS rules are met.

(9) The list of required DME items subject to face-to-face requirements is posted and maintained by CMS. Please refer to the CMS.gov website for an active link to this list.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 7-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, adopt filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18

Or. Admin. R. 410-122-0180 Healthcare Common Procedure Coding System Level II Coding

(1) The Healthcare Common Procedure Coding System (HCPCS) level II is a comprehensive and standardized system that classifies similar products that are medical in nature into categories for the purpose of efficient claims processing. For each alphanumeric HCPCS code, there is descriptive terminology that identifies a category of like items. These codes are used primarily for billing purposes. The Centers for Medicare and Medicaid Services (CMS) maintain and distribute HCPCS Level II Codes.

(2) HCPCS is a system for identifying items and services. It is not a methodology or system for making coverage or payment determinations. The existence of a code does not, of itself, determine coverage for an item or service. While these codes are used for billing purposes, decisions regarding the addition, deletion, or revision of HCPCS codes are made independently of the process for making coverage and payment determinations for medical items or services. Items billed with a miscellaneous or not otherwise classified HCPCS code may be reviewed by the Division on a case-by-case basis in accordance with Chapter 410 Division 122 rules.

(3) The Division uses the HCPCS Level II Code Set to ensure that claims are processed in an orderly and consistent manner.

(4) When requesting authorization and submitting claims, DMEPOS providers must use HCPCS codes to identify the items they are billing. The descriptor that is assigned to a code represents the definition of the items and services that can be billed using that code.

(5) This rule division may not contain all code updates needed to report medical services and supplies.

(6) For the most up-to-date information on code additions, changes, or deletions, refer to the fee schedule posted on the Division Web site.

(7) The Division fee schedule is updated quarterly and lists the current HCPCS codes in an alphanumeric index.

(8) Newly established temporary codes and effective dates for their use are also posted on the Division website at https://www.oregon.gov/oha/hsd/ohp/pages/fee-schedule.aspx.

(9) CMS updates new, revised, and discontinued HCPCS codes on a quarterly basis.

(10) The Medicare Pricing, Data Analysis and Coding (PDAC) contractor assists in determining which HCPCS code shall be used to describe and bill DMEPOS items. Refer to the product classification list on the PDAC contractor website for appropriate HCPCS codes.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 413.042 & 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 39-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 3-2011, f. 3-23-11, cert. ef. 3-25-11
DMAP 26-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 63-2001, f. 12-28-01, cert. ef. 1-1-02
OMAP 54-2001(Temp), f. 10-31-01, cert. ef. 11-1-01 thru 4-15-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 26-1999, f. & cert. ef. 6-4-99
OMAP 12-1999(Temp), f. & cert. ef. 4-1-99 thru 9-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91, Renumbered from 410-122-0100
HR 7-1990, f. 3-30-89, cert. ef. 4-1-89, Renumbered from 461-024-0200
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 6-1989(Temp), f. 2-9-89, cert. ef. 3-1-89

Or. Admin. R. 410-122-0182 Legend

This rule is retroactive and applies to services rendered on or after January 1, 2009.

(1) The Division uses abbreviations in the tables within this division.

(2) This rule explains the meaning of these abbreviations.

(3) PA — Prior authorization (PA): “PA” indicates that PA is required, even if the client has private insurance. See OAR 410-122-0040 for more information about PA requirements.

(4) PC — Purchase: “PC” indicates that purchase of this item is covered for payment by the Division.

(5) RT — Rent: “RT” indicates that the rental of this item is covered for payment by the Division.

(6) MR — Months Rented:

(a) “13” — Indicates up to 13 consecutive months of continuous rental, unless otherwise noted in Division 122 rules, and determined when either the Division fee schedule purchase price is met for the item, when the usual purchase price is reached, or the actual charge is met (whichever is lowest); at which time, the equipment is considered paid for and owned by the client. The provider must then transfer title of the equipment to the client;

(b) For any other rental situation where the Division fee schedule lists a purchase price and this purchase price is met for the item, when the usual purchase price is reached or the actual charge is met (whichever is lowest), the equipment is considered paid for and owned by the client. The provider must then transfer title of the equipment to the client.

(7) RP — Repair: “RP” indicates that repair of this item is covered for payment by the Division.

(8) NF — Nursing Facility: “NF” indicates that this procedure code is covered for payment by the Division when the client is a resident of a nursing facility.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 40-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04

Or. Admin. R. 410-122-0184 Repairs, Servicing, Replacement, Delivery, and Dispensing

(1) For indications and limitations of coverage and medical appropriateness, the Division may cover reasonable and necessary repairs, servicing, and replacement of medically appropriate, covered durable medical equipment, prosthetics, and orthotics, including those items purchased or in use before the client enrolled with the Division:

(a) Repairs:

(A) To repair means to fix or mend and to put the equipment back in good condition after damage or wear to make the equipment serviceable;

(B) Repairs (parts and labor) of DMEPOS items are performed on the base item. The replacement of parts or components that make up the base item is considered a repair;

(C) If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment may be made for the amount of the excess;

(D) Payment for repairs is not covered when:

(i) The skill of a technician is not required;

(ii) The equipment has been previously denied;

(iii) Equipment is being rented, including separately itemized charges for repair;

(iv) Equipment, parts and labor are covered under a manufacturer’s or supplier’s warranty.

(E) Code K0739 may not be used on an initial claim for equipment. Payment for any labor involved in assembling, preparing, or modifying the equipment on an initial claim is included in the allowable rate.

(b) Servicing:

(A) Additional payment for routine periodic servicing, such as testing, cleaning, regulating, and checking the client’s equipment is not covered. However, more extensive servicing that, based on the manufacturers’ recommendations may only be performed by authorized technicians, may be covered for medically appropriate client-owned equipment;

(B) Payment for maintenance/service is not covered for rented equipment. Providers must maintain, repair, or replace rented equipment at no charge to the Division or the client during the authorized rental period. The Division may authorize payment for covered servicing of capped rental items after six months have passed from the end of the final paid rental month. Use the corresponding Healthcare Common Procedure Coding System (HCPCS) code for the equipment in need of servicing at no more than the rental fee schedule allowable amount;

(C) Up to one (1) month’s rental shall be reimbursed at the level of either the equipment provided, or the equipment being repaired, whichever is less costly;

(D) Maintenance and servicing that includes parts and labor covered under a manufacturer’s or supplier’s warranty is not covered.

(i) Providers must notify clients of warranty coverage and honor all warranties under applicable State law, whether it is a warranty from the manufacturer or the supplier. All equipment under warranty shall be repaired or replaced at no charge to the Division or the client in accordance with ORS 646A.460 to 646A.476.

(ii) If the dispensing provider is unable to fulfill the warranty and the equipment continues to be medically appropriate, the provider is responsible for any costs incurred to have a different provider repair or replace the equipment.

(A) Temporary Replacement: One (1) month’s rental of temporary replacement equipment (K0462) may be reimbursed when client-owned equipment, such as a wheelchair, is being repaired. The equipment in need of repair must be unavailable for use for more than one (1) day;

(B) Permanent Replacement: Situations involving the provision of medically appropriate items when there is a change in the client’s condition that warrants a new device, the client has outgrown the equipment, or when reasonable wear and tear renders the item non-functioning and not repairable, and there is coverage for the specific item identified in chapter 410, division 122;

(C) Equipment that the client owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster.

(D) Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment:

(i) Reasonable useful lifetime of DME is no less than five (5) years unless otherwise specified in Chapter 410, Division 122 rules;

(ii) Computation of the useful lifetime is based on when the equipment is delivered to the client, not the age of the equipment;

(iii) Replacement of the base item due to wear is not covered during the reasonable useful lifetime of the equipment;

(iv) During the reasonable useful lifetime, repair up to the cost of replacement (but not actual replacement for medically appropriate equipment owned by the client) may be covered.

(E) Cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment may not be covered.

(d) Delivery:

(A) Providers may deliver directly to the client or the authorized designee;

(B) Providers, their employees, or anyone else having a financial interest in the delivery of an item may not sign and accept an item on behalf of a client;

(C) Provider shall have documentation on file containing a description of the item delivered to the client to determine the accuracy of claims coding including, but not limited to, an invoice or statement in the provider records.

(D) A provider may deliver DMEPOS to a client in a hospital or nursing facility for the purpose of fitting or training the client in its proper use. This may be done up to two (2) days prior to the client's anticipated discharge to home. On the claim, bill the date of service as the date of discharge and specify the place of service as the client’s home. The item must be for subsequent use in the client's home;

(E) A provider may deliver DMEPOS to a client's home in anticipation of a discharge from a hospital or nursing facility. The provider may arrange for actual delivery approximately two (2) days prior to the client's anticipated discharge to home. On the claim, bill the date of service as the date of discharge and specify the place of service as the client’s home;

(F) No payment is made on dates of service the client receives training or fitting in the hospital or nursing facility for a particular DMEPOS item.

(e) For Dispensing Refills:

(A) For DMEPOS products that are supplied as refills to the original order, providers must contact the client or designee prior to dispensing the refill to check the quantity on hand and continued need for the product;

(B) Contact with the client or designee regarding refills must take place no sooner than thirty (30) calendar days prior to the expected end of the current supply. Contact with the client or designee regarding refills may only take place no sooner than approximately fourteen (14) calendar days prior to the delivery/shipping date;

(C) For subsequent deliveries of refills, the provider shall deliver the DMEPOS product no sooner than ten (10) calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. The Division shall allow for the processing of claims for refills delivered/shipped prior to the client exhausting their supply, but the provider must not dispense supplies that exceed a client’s expected utilization;

(D) Supplies dispensed are based on the practitioner’s order. Regardless of utilization, a provider may not dispense more than a three (3) -month quantity of supplies at a time. This three (3) -month dispensing restriction for supplies may be further limited by rule limitations of coverage;

(E) The provider may not automatically ship, dispense, or deliver a quantity of supplies on a predetermined regular basis, even if the client or designee has “authorized” this in advance;

(F) Shipping and handling charges are not covered as this is included in the allowable rate for the DMEPOS product.

(f) The following services are not eligible for reimbursement:

(A) Pick-up, delivery, shipping, and handling charges for DMEPOS, whether rented or purchased including travel time:

(i) These costs are included in the calculations for allowable rates;

(ii)These charges are not billable to the client.

(B) Supplies used with DME or a prosthetic device prior to discharge from a hospital or nursing facility;

(C) Surgical dressings, urological supplies, or ostomy supplies applied in the hospital or nursing facility, including items worn home by the client.

(2) Documentation Requirements:

(a) For repairs, servicing, and temporary replacement, a new practitioner's order is not required;

(b) Submit the following documentation with the prior authorization (PA) request:

(A) For repairs and servicing:

(i) Narrative description, manufacturer and brand name/model name and number, serial number, and original date of purchase for the covered equipment in need of repair;

(ii) Itemized statement of parts needed for repair including the estimated date of service, manufacturer’s name (if billing for parts, include manufacturer’s name and part number for each part), product name, part number, manufacturer’s suggested retail price or manufacturer’s invoice price, and estimated labor time; and

(iii) Justification of the client’s medical need for the item and statement that the client owns the equipment in need of repair.

(B) For temporary replacement:

(i) Narrative description, manufacturer and brand name/model name and number, serial number, and original date of purchase for the covered equipment in need of repair;

(ii) Narrative description, manufacturer and brand name/model name, and number of the replacement equipment;

(iii) Itemized statement of parts needed for repair including the estimated date of service, manufacturer’s name (if billing for parts, include manufacturer’s name and part number for each part), product name, part number, manufacturer’s suggested retail price or manufacturer’s invoice price, and estimated labor time;

(iv) Justification of the client’s medical need for the item and statement that the client owns the equipment in need of repair; and

(v) Description of why the repair takes more than one (1) day to complete.

(D) For proof of delivery, DMEPOS providers shall:

(i) Maintain proof of delivery documentation to the client in their records for seven (7) years;

(ii) Maintain documentation that supports conditions of coverage in this rule are met;

(iii) Make proof of delivery documentation available to the Division upon request.

(d) A signed and dated delivery slip is required for items delivered directly by the provider to the client or designee. The delivery slip must include the following:

(A) When a designee signs the delivery slip, their relationship to the client must be noted and the signature legible;

(B) The client or designee’s signature with the date the items were received;

(D) Quantity, brand name, serial number, and a detailed description of the items being delivered;

(E) The date of signature on the delivery slip must be the date the DMEPOS item is received by the client or designee; and

(F) The date the client receives the item is the date of service.

(e) If the provider uses a delivery or shipping service or mail order, proof of delivery must include the service’s tracking slip and the provider’s own shipping invoice:

(A) The provider’s shipping invoice must include the:

(i) Client’s name;

(ii) Quantity, brand name, serial number, and a detailed description of the items being delivered;

(iii) Delivery service’s package identification number associated with each individual client’s package with a unique identification number and delivery address, including the actual date of delivery, if possible; and

(iv) The shipping date must be used as the date of service, unless the actual date of delivery is available, then use this date as the date of service.

(B) The delivery service’s tracking slip must reference:

(i) Each client’s packages; and

(ii) The delivery address and corresponding package identification number given by the delivery service.

(f) Providers must utilize a signed and dated return postage-paid delivery or shipping invoice from the client or designee as a form of proof of delivery that must contain the following information:

(A) Client’s name;

(B) Quantity, brand name, serial number, and a detailed description of items being delivered;

(g) Delivery to nursing facilities or hospitals:

(A) The date of service is the date the DMEPOS item is received by the nursing facility if delivered by the DMEPOS provider;

(B) The date of service is the shipping date (unless the actual delivery date is known and documented) if the DMEPOS provider uses a delivery or shipping service.

(h) For those clients who are residents of an assisted living facility, a twenty-four (24) hour residential facility, an adult foster home, a child foster home, a private home or other similar living environment, providers must ensure supplies are identified and labeled for use only by the specific client for whom the supplies or items are intended.

(3) Procedure codes:

(a) Replacement parts for wheelchair repair are billed using the specific HCPCS code, if one exists, or code K0108 (other accessories);

(b) K0739:

(A) Repair or non-routine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes;

(B) This code is used for services not covered by other codes or combination of codes in reference to the repairs of DMEPOS.

(c) K0108 – Wheelchair component or accessory, not otherwise specified - PA is required when the billed charge for an item is greater than $150;

(d) E1399 – Durable medical equipment, miscellaneous, - PA is required when the billed charge for an item is greater than $150;

(e) K0462 – Temporary replacement for client-owned equipment being repaired, any type - No PA required.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
DMAP 20-2026, amend filed 06/03/2026, effective 06/03/2026
DMAP 95-2025, temporary amend filed 12/26/2025, effective 12/26/2025 through 06/23/2026
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04

Or. Admin. R. 410-122-0186 Payment Methodology

(1) Effective October 1, 2024, the Division utilizes a payment methodology for covered durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that is generally based on the 2024 Medicare fee schedule.

(a) The Division fee schedule amount is 80 percent of 2024 Medicare Fee Schedule for items covered by Medicare and the Division using a state-wide average of the rural and urban Medicare rates except for:

(A) Complex Rehabilitation items and services other than power wheelchairs, fee schedule amounts are 88 percent of 2024 Medicare Fee Schedule (See Table 122-0186-1 for list of Complex Rehabilitation codes subject to this pricing); and

(B) Rental rates for Group 1 power wheelchairs (K0813-K0816) and Group 2 power wheelchairs with no added power option (K0820-K0829) fee schedule amounts are 55 percent of 2024 Medicare Fee Schedule; and

(C) Group 2 power wheelchairs (K0835-K0843) and Group 3 power wheelchairs (K0848-K0864) fee schedule amounts are 58.7 percent of 2024 Medicare Fee Schedule; and

(D) Unlisted procedures (e.g. E1399, K0108, A9999) are based upon 75 percent of Manufacturer’s Suggested Retail Price (MSRP). If MSRP is not available, the amount is based upon acquisition cost plus 20 percent .

(b) For new codes added by the Center for Medicare and Medicaid Services (CMS) after October 1, 2024; payment shall be based on the most current Medicare fee schedule and shall follow the same payment methodology as stated in section (1)(a)(A-D) of this rule. For new codes that do not appear on the current Medicare fee schedule, rates shall be based on the actuarial calculations used for rate setting for the CCO rate for the service and shall be published as a single state-wide rate;

(c) DMEPOS rates are published on the Fee-For-Service (FFS) Medical-Dental Fee Schedule. These schedules, along with their effective dates, are posted on the OHP FFS Fee Schedule web page.

(d) The Division shall reimburse any manually priced codes and any new codes that require manual pricing using the methodology as stated in section (10)(b-c)(11) of this rule.

(2) DMEPOS providers are required to use the Healthcare Common Procedure Coding System (HCPCS) to identify billing codes for DMEPOS items or services. DMEPOS providers shall use the product classification list on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor website on the date of service for coding verification. An official product review coding decision from an organization such as PDAC is not necessary.

(3) DMEPOS providers are required to use the HCPCS to identify miscellaneous billing codes for items or services. DMEPOS providers shall use the product classification list on the Medicare PDAC contractor website on the date of service for coding verification. An official product review coding decision from an organization such as PDAC is not necessary.

(4) DMEPOS providers are required to use specific miscellaneous HCPCS code to identify an item or service when directed in accordance with Division 122 rules (e.g. standing frames, bath equipment, adaptive car seats).

(5) DMEPOS providers are required to determine whether there is an existing national HCPCS code that adequately describes the DMEPOS before using a miscellaneous or not otherwise classified HCPCS code to bill an item or service. When a HCPCS code exists, the provider shall use that code to bill the item or service;

(a) In the absence of an existing HCPCS code that describes a given product, DMEPOS providers shall use a miscellaneous or not otherwise classified HCPCS code (e.g. E1399, K0108, A9999) that best represents the item or service;

(b) DMEPOS providers billing separately for a service or component that is included in another HCPCS code shall use miscellaneous HCPCS code A9900 to bill the item or supply. DMEPOS providers must not “unbundle” services so that a provider payment is higher than the amount allowed by this rule;

(6) Information about the PDAC and the PDAC’s product classification list can be found at http://www.dmepdac.com.

(7) Prior authorization (PA) is required for all miscellaneous and not otherwise classified HCPCS codes (e.g. E1399, K0108, A9999, A9900) when the billed charge is greater than $150 per each unit. The DMEPOS provider shall submit the following documentation:

(a) A copy of the items from subsections (10)(b) and (c) that will be used to bill;

(b) Name of the manufacturer, description of the item, including product name or model name and number, and serial number when applicable;

(d) A picture of the item upon request by the Division.

(8) All miscellaneous and not otherwise classified HCPCS codes (e.g. E1399, K0108, A9999, A9900) with a billed charge of $150 or less per each unit do not require PA; however, are subject to service limitations of the Division’s rules; and

(a) The payment amount shall not exceed 75 percent of MSRP; and

(b) The DMEPOS provider must retain documentation of the quote, invoice, or bill to allow the Division to verify through audit procedures.

(9) The Division may at any time before or after payment review items that exceed the maximum allowable on a case-by-case basis and may ask the DMEPOS provider to submit the following documentation for reimbursement:

(a) Documentation which supports that the client meets all of the coverage criteria for the less costly alternative; and,

(b) A comprehensive evaluation by a licensed clinician (who is not an employee of or otherwise paid by a provider) that clearly explains why the less costly alternative is not sufficient to meet the client’s medical needs, and;

(d) The expected outcome or change in the client’s condition.

(10) The Division shall reimburse for the lowest level of service that meets medical appropriateness. (See OAR 410-120-1280 Billing; and 410-120-1340 Payment). Reimbursement is calculated using the lesser of the following:

(a) The Division fee schedule amount, using the above methodology in subsections (1) (a) and (b); or

(b) Seventy-five (75) percent of MSRP, verifiable with quote from the manufacturer that clearly states the amount indicated is MSRP; or

(11) When MSRP is not available, the Division shall use the DMEPOS provider’s acquisition cost plus 20 percent, verifiable with a quote from the provider that clearly states the amount indicated is acquisition cost, in place of the MSRP in section (10)(b) of this rule.

(12) For rented equipment, the equipment is considered paid for and owned by the client when the Division fee schedule allowable is met or the actual charge from the provider is met, whichever is lowest. The DMEPOS provider must transfer title of the equipment to the client.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 68-2025, amend filed 09/11/2025, effective 09/15/2025
DMAP 36-2025, temporary amend filed 03/31/2025, effective 03/31/2025 through 09/26/2025
DMAP 1-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 3-2016, f. & cert. ef. 2-3-16
DMAP 44-2014, f. & cert. ef. 7-11-14
DMAP 2-2014(Temp), f. 1-15-14, cert. ef. 2-1-14 thru 7-31-14
DMAP 57-2012, f. & cert. ef 12-27-12
DMAP 31-2012(Temp), f. 6-29-12, cert. ef. 7-1-12 thru 12-27-12
DMAP 42-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04

Or. Admin. R. 410-122-0188 DMEPOS Rebate Agreements

(1) The Health Systems Division has a Centers for Medicare and Medicaid Services (CMS) approved DMEPOS Rebate Agreement.

(2) The Division negotiates DMEPOS Rebate Agreements for specific products through the Sovereign States Drug Consortium (SSDC) multi-state pool and DMEPOS manufacturers. Negotiations are confidential, and shall not be disclosed, except in connection with an agreement/contract or as may be required by law. Confidentiality is required of any third party involved in administration of the agreement/contract.

(3) Manufacturers may submit rebate offers for consideration to include their product(s) on the Preferred DME List (PDMEL), after gaining access to the SSDC secure web-based offer entry system.

(4) Manufacturers must abide by requirements of the SSDC.

(5) The PDMEL shall consist of DMEPOS that the Food and Drug Administration (FDA) has determined to be safe and effective

(6) Upon acceptance of the offer:

(a) The SSDC will notify manufacturers of the status of their offer(s);

(b) Supplemental Agreements will be executed after signed by all parties, approved by CMS if required, and products may be added to the PDMEL;

(c) The Division may contract for the functions of tracking utilization, invoicing, and dispute resolution for rebate products.

(7) The division will develop a PDMEL, however specific items may be categorized together to create specific lists such as, but not limited to the Preferred Diabetic Supply List (PDSL).

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 59-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 42-2011, f. 12-21-11, cert. ef. 1-1-12

Or. Admin. R. 410-122-0200 Pulse Oximeter for Home Use

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover a tamper-proof (calibrated, preset, and sealed) pulse oximeter for home use when all of the following criteria are met:

(A) The client has frequently fluctuating oxygen saturation levels that are clinically significant;

(B) Measurements are integral in dictating acute therapeutic intervention;

(D) The client has a caregiver trained to provide whatever care is needed to reverse the low oxygen saturation level ordered by the practitioner;

(b) Some examples of when a home pulse oximeter may be covered include the following:

(A) When weaning a client from home oxygen or a ventilator;

(B) When a change in the client's physical condition requires an adjustment in the liter flow of their home oxygen needs;

(D) To monitor a client on mechanical ventilation at home;

(E) To monitor a client with a tracheostomy at home;

(F) To periodically re-assess the need for long-term oxygen in the home;

(G) Infants with chronic lung disease (e.g., bronchopulmonary dysplasia);

(H) Premature infants on active therapy for apnea;

(I) When a client exhibits a certain unstable illness and has compromised or potentially compromised respiratory status or airways;

(J) When evidence-based clinical practice guidelines support the need;

(c) Home pulse oximetry for indications other than those listed above may be covered on a case-by-case basis upon medical review by the Division’s Policy Unit;

(d) The durable medical equipment prosthetics, orthotics and supplies (DMEPOS) provider is responsible to ensure the following services for home pulse oximetry are provided:

(A) For purchase or rental of a pulse oximeter for home use:

(i) Training client or caregiver on the use and care of the equipment and developing an emergency plan, such as dialing immediate emergency services, are performed at the time of delivery or prior to equipment usage; and

(ii) A follow-up telephone call or home visit is conducted within the first 30 days of equipment setup to ensure client’s continuation and proper use of the equipment;

(B) For rental of a pulse oximeter for home use:

(i) 24-hour/7 day a week respiratory therapist on-call availability for troubleshooting, exchanging of malfunctioning equipment, etc.; and

(ii) The allowable rental fee includes all equipment, supplies, services, including all probes, routine maintenance, and necessary training for the effective use of the pulse oximeter;

(e) The Division may cover replacement probes for a client-owned covered oximeter as ordered by the treating practitioner for continued use:

(A) The Division shall reimburse for the least costly alternative for payment of probes, whether disposable or reusable, which meets the medical need of the client;

(B) A reusable probe must be used when it is the least costly alternative, rather than a disposable probe, unless the client’s medical records clearly substantiate why a reusable probe is contraindicated;

(f) The use of home pulse oximetry for indications considered experimental and investigational, including the following, are not covered:

(A) Asthma management;

(B) When used alone as a screening/testing technique for suspected obstructive sleep apnea;

(2) Documentation Requirements:

(a) Submit the following documentation for prior authorization (PA) review:

(A) An order from the treating practitioner that clearly specifies the medical appropriateness for home pulse oximetry testing;

(B) Documentation of signs/symptoms/medical condition exhibited by the client, that require continuous pulse oximetry monitoring as identified by the need for oxygen titration, frequent suctioning or ventilator adjustments, etc.;

(C) Plan of treatment that identifies a trained caregiver is available to perform the testing, document the frequency and the results and implement the appropriate therapeutic intervention, when necessary;

(D) For probes for a client-owned oximeter, documentation of which type of probes are prescribed and why the probes requested are the least costly alternative;

(E) Other medical records that corroborate conditions for coverage are met as specified in this rule;

(b) History and physical exam and progress notes must be available for review by the Division, upon request.

(3) Procedure Codes:

(a) A4606 — Oxygen probe for use with client-owned oximeter device, replacement;

(b) E0445 — Oximeter device for measuring blood oxygen levels non-invasively;

(A) For adults, PA is required;

(B) The Division will purchase or rent on a monthly basis;

(D) Item considered purchased after seven (7) months of rent;

(E) Quantity (units) is one on a given date of service.

(4) Refer to Coverage Table OAR 410-122-0203-1.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 32-1999, f. & cert. ef. 10-1-99
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0202 Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover the initial three (3) month trial period of a positive airway pressure (PAP) device for treatment of obstructive sleep apnea (OSA) when the client meets the conditions of coverage in OAR 410-122-0080 and when all the following guidelines and criteria are met:

(A) The client has a face-to-face clinical evaluation by the treating practitioner prior to a sleep test to assess the client for obstructive sleep apnea;

(B) The client has a home sleep test or a polysomnogram performed in a facility-based laboratory to test for obstructive sleep apnea and the type of sleep test performed meets all CMS requirements for a valid sleep test and in accordance with Prioritized List of Health Services Diagnostic Testing for Obstructive Sleep Apnea (OSA) Guideline Note;

(C) The client demonstrates a positive diagnosis of OSA, as defined in the Prioritized List of Health Services Treatment of Sleep Apnea Guideline Note; and

(D) The client or their caregiver has received instruction from the supplier in the proper use and care of the PAP device equipment and accessories.

(b) Prior Authorization (PA) is not required for PAP device (E0601) rental and the purchase of prescribed accessories during the initial three (3) month trial period. The DMEPOS provider is responsible to ensure all requirements in this rule are met.

(c) A Bi-level Positive Airway Pressure (BiPAP) device without backup rate (E0470) may be covered for treatment of OSA when the following criteria are met:

(A) Criteria in (1)(a)(A)–(D) of this rule; and

(B) A Continuous Positive Airway Pressure (CPAP) or Automatic Positive Airway Pressure (APAP) device (E0601) has been tried and proven ineffective or there is documentation of medical contraindication to E0601 devices as determined by the treating practitioner. Ineffective use is defined as documented failure to meet therapeutic goals using a CPAP/APAP device during the titration period of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings);

(C) If a CPAP/APAP device is tried and found ineffective during the initial facility-based titration or three (3) month home trial, substitution of a BiPAP does not require a new face-to-face clinical evaluation or sleep test;

(D) If a CPAP/APAP device has been used for more than three (3) months and the client is switched to a BiPAP, a clinical re-evaluation must occur, but a new sleep test is not required. A new three (3) month trial shall begin for use of the BIPAP.

(d) PA is not required for BiPAP device (E0470) rental and purchase of prescribed accessories during the initial three (3) month trial period. The DMEPOS provider is responsible to ensure all requirements in this rule are met.

(2) Continued Coverage of PAP device (PA Required):

(a) Purchase or ongoing rental of a PAP device (E0601 or E0470) beyond the three-month trial period may be covered when the conditions of coverage have been met per the Prioritized List of Health Services Treatment of Sleep Apnea Guideline Note. The DMEPOS provider must submit the following documentation, with request for authorization, prior to the fourth (4th) date of service:

(A) A face-to-face re-evaluation visit conducted by the treating practitioner no sooner than the thirty-first (31st) day but no later than the ninety-first (91st) day after initiating therapy that supports client’s clinical benefit, compliance, and demonstrates symptoms of OSA are improved; and

(B) Objective evidence of adherence to use of the PAP device, including a summary of PAP compliance report through a direct download of usage. PAP compliance report data can be documented by the treating practitioner in the clinical re-evaluation. Adherence to therapy is defined as use of PAP four (4) hours or more per night on seventy percent (70%) of nights during a consecutive thirty (30) day period anytime during the first three months of initial usage;

(C) If the clinical re-evaluation by the treating practitioner does not occur until after the ninety-first (91st) day but the re-evaluation demonstrates the client is compliant, as defined in this rule, and benefiting from PAP therapy at the time of their re-evaluation, the provider shall submit a PA request for continued coverage. The request for authorization shall include the following documentation:

(i) The clinical re-evaluation with the treating practitioner that demonstrates the client is compliant, as defined in this rule, and benefiting from the PAP therapy at the time of the re-evaluation; and

(ii) Objective evidence of adherence to use of the PAP device, including a summary of PAP compliance report through a direct download of usage, at the time of the client’s re-evaluation. PAP compliance report data can be documented by the treating practitioner in the clinical re-evaluation. Adherence to therapy is defined as use of PAP four (4) hours or more per night on seventy percent (70%) of nights during a consecutive thirty (30) day period prior to client’s re-evaluation.

(D) If there is a break in billing of sixty (60) days or more between the end of the trial period and the request to purchase or continue renting the PAP device, the provider shall also supply current objective evidence of adherence to use of the PAP device from the date the prior authorization request to resume coverage is submitted;

(i) Adherence to therapy is defined as use of PAP four (4) hours or more per night on seventy percent (70%) of nights during a consecutive thirty (30) day period;

(ii) Capped rental period begins the date the equipment is dispensed and shall not extend beyond the thirteenth (13th) consecutive month;

(b) If objective data does not support compliance and efficacy, extending the trial period beyond the third month may be approved on a case-by-case basis by the appropriate authorizing unit. To ask for an exception, the DMEPOS provider must submit the following documentation with the prior authorization request:

(A) Documentation of a face-to-face visit with the treating practitioner clearly specifying a treatment plan with measurable goals to improve adherence to treatment; and

(B) Objective evidence of PAP use, including a PAP summary report through direct download of usage;

(C) The trial period may extend up to a maximum of two (2) months to allow the client to achieve compliance, as defined in this rule, and therapeutic benefit;

(D) Purchase or ongoing rental of a PAP device (E0601 or E0470) beyond the two (2) month extended trial period may be covered when the conditions for continued coverage have been met. Submit the following documentation with request for prior authorization:

(i) A face-to-face clinical re-evaluation conducted by the treating practitioner which documents the following:

(I) Client is compliant and benefiting from PAP therapy; and

(II) Objective evidence of adherence to use of the PAP device, including a summary of PAP compliance report through a direct download of usage;

(ii) Adherence to therapy is defined as use of PAP four (4) hours or more per night on seventy percent (70%) of nights during a consecutive thirty (30) day period anytime during the two (2) month extended rental period.

(E) If there is a break in billing of sixty (60) days or more between the end of the extended trial period and the request to purchase or continue renting the PAP device, the provider shall also supply current objective evidence of adherence to use of the PAP device from the date the prior authorization request to resume coverage is submitted;

(i) Adherence to therapy is defined as use of PAP four (4) hours or more per night on seventy percent (70%) of nights during a consecutive thirty (30) day period;

(ii) Capped rental period begins the date the equipment is dispensed and shall not extend beyond the thirteenth (13th) consecutive month.

(A) Face-to-face clinical re-evaluation by the treating practitioner to determine etiology of the failure to respond to PAP therapy; and

(B) Repeat sleep test in a facility-based setting if deemed necessary by the treating practitioner. This may be a repeat diagnostic titration or split night study in accordance with the Prioritized List of Health Services Diagnostic Testing for Obstructive Sleep Apnea (OSA) Guideline Note.

(d) For a client using a PAP device prior to Oregon Health Plan (OHP) enrollment, continuing coverage for the device and related accessories may be authorized on a case-by-case basis upon submission and review of the following required documentation:

(A) Record of initial delivery date when the PAP equipment was dispensed; and

(B) Documentation from the client’s treating practitioner to support the diagnosis of OSA and that coverage criteria in this rule are met in accordance with the Prioritized List of Health Services Treatment of Sleep Apnea Guideline Note; and

(C) A facility-based polysomnogram report or home sleep test that meets all CMS requirements for a valid sleep test in accordance with the Prioritized List of Health Services Diagnostic Testing for Obstructive Sleep Apnea (OSA) Guideline Note; and

(D) Objective evidence of client’s ongoing adherence to PAP therapy at the time the prior authorization for continued coverage is requested. Adherence to therapy is defined as use of PAP four (4) hours or more per night on seventy percent (70%) of nights during a consecutive thirty (30) day period.

(e) The continued rental of PAP equipment and the purchase of related accessories shall not be reimbursed, under any circumstance, when client is not using the equipment or non-compliant with its use;

(A) It is the provider’s responsibility to monitor appropriate and effective use of the device as ordered by the treating practitioner; and

(B) When the equipment is not being used as prescribed or member is non-compliant with its use, it is the provider’s responsibility to stop billing for the continued rental of the equipment and the purchase of related accessories and supplies.

(3) Accessories:

(a) Either a non-heated (E0561) or heated (E0562) humidifier is covered and reimbursed separately when ordered by the treating practitioner for use with a covered PAP device (E0470, E0601). No PA is required;

(b) Accessories are separately reimbursable at the time of initial issue and when replaced. For replacement of accessories beyond initial issue:

(A) Suppliers are required to verify the PAP or BiPAP device is still in use;

(B) Regardless of utilization, a supplier must not dispense more than a three (3) month quantity of accessories;

(C) Automatic shipments on a pre-determined basis, even if authorized by the client or designee, are not allowed. An order refill does not have to be approved by the ordering practitioner. However, a client or their caregiver must request specific ongoing PAP supplies and accessories, subject to rule limitations and requirements, before they are dispensed. The DMEPOS provider shall not automatically dispense a quantity of supplies and accessories on a predetermined regular basis, even if the client has "authorized" this in advance;

(A) A4604 — 1 per 3 months;

(B) A7027 — 1 per 3 months;

(D) A7029 — 2 per month;

(E) A7030 — 1 per 3 months;

(F) A7031 — 1 per month;

(G) A7032 — 2 per month;

(H) A7033 — 2 per month;

(I) A7034 — 1 per 3 months;

(J) A7035 — 1 per 6 months;

(K) A7036 — 1 per 6 months;

(L) A7037 — 1 per 3 months;

(M) A7038 — 2 per month;

(N) A7039 — 1 per 6 months;

(O) A7046 — 1 per 6 months.

(4) Replacement of PAP Device:

(a) For PAP devices initially covered through the Oregon Health Plan, a replacement PAP may be covered on a case-by-case basis in accordance with OAR 410-122-0184. The DMEPOS provider must submit the following documentation with the PA request:

(A) An order for the replacement PAP device from the treating practitioner; and

(B) A face-to-face clinical evaluation by the treating practitioner that documents the present medical need for replacement and confirms the beneficiary continues to use and benefit from the PAP device.

(b) For PAP devices not initially covered through the Oregon Health Plan, a replacement PAP may be covered on a case-by-case basis in accordance with OAR 410-122-0184. The DMEPOS provider must submit records to support the client meets criteria in (1)(a)(A)–(D) of this rule and the following documentation with the PA request:

(A) An order for the replacement PAP device from the treating practitioner;

(5) Prior authorization is obtained from the same authorizing authority as specified in OAR 410-122-0040. PA is required for the following:

(a) All subsequent rentals or purchase of a PAP device starting with the fourth (4th) month date of service;

(b) Quantities of PAP accessories that exceed their usual maximum number as defined in (3)(c)(A-O);

(6) Mandibular advancement devices (oral appliances) may be covered for those for whom CPAP fails or is contraindicated. A face-to-face clinical evaluation with the treating practitioner is required to document the presence of either condition and the medical necessity for the device. If a custom fabricated device is prescribed, the practitioner’s evaluation must also include why a less costly prefabricated device will not meet the client’s needs. No PA is required.

(7) Reimbursement:

(a) Rental charges apply toward purchase;

(b) Capped rental period begins the date the equipment is dispensed and shall not extend beyond the thirteenth (13th) consecutive month;

(c) Equipment is considered purchased either upon completion of the capped rental period, after the Division fee schedule purchase price is met, or when the actual charge from the provider is met, whichever is less;

(d) Accessories are separately reimbursable at the time of initial issue.

(8) Documentation Requirements:

(a) For services requiring PA, submit documentation that supports coverage criteria and guidelines in this rule are met;

(b) Medical records and documentation to support the client meets criteria and conditions of coverage in this rule must be on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request.

(9) For children and youth 18 years old or younger: the Division may cover a positive airway pressure (PAP) device for treatment of obstructive sleep apnea (OSA) when the criteria and conditions of coverage in the Prioritized List of Health Services Treatment of Sleep Apnea Guideline Note are met.

(10) A Respiratory Assist Device (RAD) with backup rate (E0471) is not medically indicated for the treatment of obstructive sleep apnea. Coverage, coding, and documentation requirements are addressed in OAR 410-122-0205 Respiratory Assist Devices.

(11) Table 122-0202 — PAP Devices.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 2-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 81-2014, f. 12-23-14, cert. ef. 1-1-15
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 11-2009, f. & cert. ef. 6-1-09
DMAP 44-2008(Temp), f. 12-17-08, cert. ef. 1-1-09 thru 6-15-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 76-2004, f. 9-30-04, cert. ef. 10-1-04
OMAP 46-2004, f. 7-22-04, cert. ef. 8-1-04
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0203 Oxygen and Oxygen Equipment

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover home oxygen therapy services. Refer to Table 122-0203-1 and the following guidelines:

(a) For children under age 21 when the treating practitioner has determined oxygen services to be medically appropriate; or

(b) For adults aged 21 years of age and older who are fully dual-eligible clients (Medicare clients who are also eligible for Medicaid/Oregon Health Plan (OHP); See definition in General Rules, OAR 410-120-0000), the Division may cover oxygen services as follows:

(A) If Medicare paid on the claim for the oxygen equipment, the Division may provide reimbursement;

(B) If Medicare denied payment on the claim for the oxygen equipment, the Division shall not provide reimbursement in accordance with Medicare rules and regulations;

(C) Refer to Table 122-0203-2 for additional details on Medicare’s reimbursement limitation of 36 monthly rental payments;

(c) For adults 21 years of age and older who are not eligible for Medicare (only eligible for Medicaid/OHP), Prior Authorization (PA) is required and all of the following conditions must be met:

(A) The treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed at the time of need; and

(B) The client's blood gas study meets the criteria stated below; and

(C) The qualifying blood gas study was performed by a treating practitioner or by a qualified provider or supplier of laboratory services; and

(D) The provision of oxygen and oxygen equipment shall improve the client’s condition.

(d) Group I criteria include any of the following:

(A) An arterial partial pressure of oxygen (PO2) at or below 55 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88 percent taken at rest (awake) while breathing room air; or

(B) An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88 percent, taken during sleep for a client who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry) at or above 89 percent while awake. In this instance, oxygen and oxygen equipment is only necessary during sleep; or

(C) A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation (e.g. peripheral pulse oximetry reading) more than five (5) percent from baseline saturation, taken during sleep and associated with symptoms of hypoxemia such as  impairment of cognitive processes and nocturnal restlessness or insomnia (not all-inclusive).In this instance, oxygen and oxygen equipment is only necessary during sleep; or

(D) An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88 percent, taken during exercise for a client who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or above 89 percent during the day while at rest. In this instance, portable oxygen and oxygen equipment is only necessary while awake and during exercise;

(e) Group II criteria: An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent; and any of the following:

(A) Dependent edema suggesting congestive heart failure; or

(B) Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure; gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF); or

(f) Group III criteria: Initial coverage of home oxygen therapy and oxygen equipment is necessary for clients in Group III, if all of the following conditions are met:

(A) Absence of hypoxemia defined in Group I and Group II above, and

(B) A covered medical condition with distinct physiologic, cognitive, and/or functional symptoms documented in high-quality, peer-reviewed literature to be improved by oxygen therapy;

(g) When both arterial blood gas (ABG) and oximetry tests have been performed on the same day under the same conditions (i.e., at rest/awake, during exercise, or during sleep), the ABG result will be used to determine if the coverage criteria were met;

(h) If an ABG test at rest/awake is nonqualifying, but an exercise or sleep oximetry test on the same day is qualifying, the oximetry test result shall determine coverage;

(i) Oxygen therapy and related services, equipment or supplies are not considered medically appropriate or medically necessary for any of the following:

(A) Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments;

(B) Dyspnea without cor pulmonale or evidence of hypoxemia;

(C) Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 shall improve the oxygenation of tissues with impaired circulation;

(D) Terminal illnesses that do not affect the ability to breathe;

(E) Emergency or stand-by oxygen systems for clients who are not regularly using oxygen since these services are precautionary and not therapeutic in nature;

(F) Topical hyperbaric oxygen chambers (A4575);

(G) When furnished by an airline (responsibility of the client);

(H) When provided/used outside the United States and its territories.

(2) Testing Specifications:

(a) The term blood gas study in this policy refers to both arterial blood gas (ABG) studies and pulse oximetry:

(A) An ABG is the direct measurement of the PO2 on a sample of arterial blood. The PO2 is reported as mm Hg.

(B) An oximetry test is the indirect measurement of arterial oxygen saturation (e.g. peripheral pulse oximetry reading) using a sensor on the ear or finger. The saturation is reported as a percent;

(C) An overnight oximetry is a stand-alone pulse oximetry continuously recorded overnight. It does not include oximetry results done as part of other overnight testing such as polysomnography or home sleep testing;

(b) The qualifying blood gas study must be one that complies with the Fiscal Intermediary, Local Carrier, or A/B Medicare Administrative Contractor (MAC) policy on the standards for conducting the test and is covered under Medicare Part A or Part B;

(c) All oxygen qualification testing must be performed by a qualified practitioner or other medical professional qualified to conduct oximetry:

(A) A DMEPOS provider is not considered a qualified provider or a qualified laboratory for purposes of this policy;

(B) Division shall not accept blood gas studies either performed or paid for by a DMEPOS provider;

(d) When oxygen is covered based on an oximetry study obtained during exercise, there must be documentation of three oximetry studies performed within the same testing session in the client’s medical record:

(A) Testing at rest without oxygen;

(B) Testing during exercise without oxygen; and

(e) All three tests must be performed in person by a treating practitioner or other medical professional qualified to conduct exercise oximetry testing;

(f) Only the qualifying test value (i.e., testing during exercise without oxygen) is used for qualification. All three (3) tests must be available upon request by the Division;

(g) The qualifying blood gas study may be performed while the client is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria.

(3) Obstructive Sleep Apnea (OSA), Polysomnography and Home Sleep Tests:

(a) Home oxygen therapy and oxygen equipment with a PAP device is covered when criteria for both Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) devices for the treatment of Obstructive Sleep Apnea are met; and

(b) For clients with OSA, it is required that the OSA be appropriately and sufficiently treated before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy and oxygen equipment. This means that the OSA must be sufficiently treated such that the underlying condition resulting in hypoxemia is unmasked. This must be demonstrated before the oxygen saturation results are obtained during polysomnography are considered qualifying for oxygen therapy and oxygen equipment; and

(c) For clients with OSA, a qualifying oxygen saturation test may only occur during a titration polysomnographic study (either split night or stand-alone). The titration PSG is one in which all of the following criteria are met:

(A) The titration is conducted over a minimum of two (2) hours; and

(B) During titration:

(i) The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or

(ii) If the initial AHI/RDI was less than an average of ten (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and

(C) Nocturnal oximetry conducted for the purpose of oxygen therapy qualification may only be performed after optimal PAP settings have been determined and the client is using the PAP device at those settings; and

(D) The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation of less than or equal to 88 percent;

(d) Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered eligible to be used for qualification for reimbursement of home oxygen and oxygen equipment.

(4) Portable Oxygen Systems:

(a) A portable oxygen system may be covered if the client is mobile within the home for Groups I and II, and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen is not covered;

(b) If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in (6) below;

(c) If a portable oxygen system is covered, the DMEPOS provider must provide whatever quantity of oxygen the client uses; the reimbursement is the same, regardless of the quantity of oxygen dispensed.

(5) Liter flow greater than four (4) LPM:

(a) If initial oxygen coverage criteria for Group 1, II, and III have been met, the Division shall pay a higher allowance for a stationary system for a flow rate of greater than four (4) LPM only when:

(A) Basic oxygen coverage criteria have been met; and

(B) A blood gas study performed while the client is on four (4) LPM meets Group I or II criteria;

(b) Payment is limited to the standard fee schedule allowance if a flow rate greater than four (4) LPM is billed and the coverage criteria for the higher allowance are not met.

(6) Documentation Requirements: The DMEPOS provider shall maintain and provide record of the face-to-face encounter and written order/prescription in addition to the qualifying documentation which supports conditions of coverage and testing requirements as specified in this rule are met;

(a) The written order for home oxygen must be completed, signed, and dated by the treating practitioner, not the DMEPOS provider, prior to delivery. The DMEPOS provider may use a written confirmation of other details of the oxygen order, or the treating practitioner can enter the other details directly, such as the means of oxygen delivery (cannula, mask, etc.) and the specifics of varying oxygen flow rates and/or non-continuous use of oxygen. There must be a treating practitioner’s signed and dated order for each item billed. Items billed before a signed and dated order has been received by the DMEPOS provider must be submitted with an EY modifier added to each affected Healthcare Common Procedure Coding System (HCPCS) code;

(b) The following special instructions apply to replacement equipment:

(A) Initial date should be the date that the replacement equipment is initially needed. This is generally understood to be the date of delivery of the oxygen equipment;

(B) A treating practitioner’s order is needed to reaffirm the medical necessity of the item for replacement of an item;

(C) Claims for the initial rental month (and only the initial rental month) must have the RA modifier (Replacement of DME item) added to the HCPCS code for the equipment when there is replacement due to reasonable useful lifetime or replacement due to damage, theft, or loss;

(D) Claims for the initial rental month must include a narrative explanation of the reason why the equipment was replaced and supporting documentation must be maintained in the DMEPOS provider’s files;

(c) In the following situations, a new order must be obtained and kept on file by the DMEPOS provider; however, a repeat blood gas study is not required:

(A) Prescribed maximum flow rate changes but remains within one of the following:

(i) Less than 1 LPM;

(ii) 1-4 LPM;

(iii) Greater than 4 LPM;

(B) Change from one type of stationary system to another (i.e., concentrator, liquid, gaseous);

(C) Change from one type of portable system to another (i.e., gaseous or liquid tanks, portable concentrator, transfilling system).

(d) Documentation for continued coverage and payment of oxygen and oxygen equipment after initial coverage must include evidence in the medical record documenting:

(A) Group I: While there is no formal requirement for re-evaluation and retesting, providers shall ensure that once qualified for home oxygen therapy, the oxygen therapy and oxygen equipment remain reasonable and necessary;

(B) Group II:

(i) Evaluation and documentation of a repeat qualifying blood gas test by the treating practitioner between the 61st and 90th days after initiation of therapy; and,

(ii) A new written order by the treating practitioner.

(i) Evaluation and documentation of a repeat qualifying blood gas test by the treating practitioner between the 61st and 90th days after initiation of therapy; and,

(ii) A new written order by the treating practitioner.

(e) Reimbursement ends unless continued payment and documentation coverage requirements in this rule are met. This documentation must be kept on file with the DMEPOS provider and available to the Division upon request.

(7) Oxygen contents:

(a) The Division allowance for rented oxygen systems includes oxygen contents necessary for one (1) month;

(b) Stationary oxygen contents (E0441, E0442) are separately payable only when the coverage criteria for home oxygen have been met and they are used with a client-owned stationary gaseous or liquid system respectively;

(c) Portable contents (E0443, E0444) are separately payable only when the coverage criteria for home oxygen have been met and:

(A) The client owns a concentrator and rents or owns a portable system; or

(B) The client rents or owns a portable system and has no stationary system (concentrator, gaseous, or liquid);

(C) If the criteria for separate payment of contents are met, they are separately payable regardless of the date that the stationary or portable system was purchased;

(d) Refer to Table 122-0203-2 for oxygen contents that may be reimbursable for dual-eligible clients.

(8) Oxygen accessory items:

(a) The allowance for rented systems includes, but is not limited to, the following accessories:

(A) Transtracheal catheters (A4608);

(B) Cannulas (A4615);

(D) Mouthpieces (A4617);

(E) Face tent (A4619);

(F) Masks (A4620, A7525);

(G) Oxygen tent (E0455);

(H) Humidifiers (E0550, E0555, E0560);

(I) Nebulizer for humidification (E0580);

(J) Regulators (E1353);

(K) Stand/rack (E1355);

(b) The DMEPOS provider must provide any accessory ordered by the practitioner;

(9) Billing for miscellaneous oxygen items:

(a) Only rented oxygen systems (E0424, E0431, E0434, E0439, E1390RR, E1405 RR, E1406RR, E1392RR) are considered for coverage;

(b) For gaseous or liquid oxygen systems or contents, report one unit of service for one (1) month rental. Do not report in cubic feet or pounds;

(c) Use the appropriate modifier if the prescribed flow rate is less than one (1) LPM (QE) or greater than four (4) LPM (QF or QG). Division only accepts these modifiers with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). Do not use these modifiers with codes for portable systems or oxygen contents;

(d) Use Code E1391 (oxygen concentrator, dual delivery port) in situations in which two (2) clients are both using the same concentrator. In this situation, this code must only be requested for one (1) of the clients;

(e) For E1405 and E1406 (oxygen and water vapor enriching systems), products must be coded as published by the Pricing, Data Analysis and Coding (PDAC) Contractor by the Centers for Medicare and Medicaid Services;

(f) Code E1392 describes a portable oxygen concentrator system. Use E1392 when billing the Division for the portable equipment add-on fee for clients using lightweight oxygen concentrators that can function as both the client’s stationary equipment and portable equipment. A portable concentrator:

(A) Weighs less than 10 pounds;

(B) Is capable of delivering 85 percent or greater oxygen concentration; and

(g) The Medicare Pricing, Data Analysis and Coding (PDAC) contractor assists DMEPOS providers and manufacturers in determining which HCPCS code shall be used to describe DMEPOS items. Refer to the product classification list on the PDAC contractor website for appropriate Healthcare Common Procedure Coding System (HCPCS) codes.

(10) Table 122-0203-1, Oxygen and Oxygen Equipment.

(11) Table 122-0203-2, Oxygen Contents.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 3-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 40-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 76-2003, f. & cert. ef. 10-1-03
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0204 Nebulizer

(1) Indications and limitations of coverage and medical appropriateness:

(a) Equipment:

(A) Small volume nebulizer:

(i) A small volume nebulizer (A7003, A7004, A7005) and related compressor (E0570) may be covered to administer inhalation drugs based on evidence-based clinical practice guidelines;

(ii) The practitioner shall have considered use of a metered dose inhaler (MDI) with and without a reservoir or spacer device and decided that, for medical reasons, the MDI was not sufficient for the administration of needed inhalation drugs.

(B) Large volume nebulizer:

(i) A large volume nebulizer (A7007, A7017), related compressor (E0565 or E0572), and water or saline (A4217 or A7018) may be covered when it is medically appropriate to deliver humidity to a client with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent;

(ii) Combination code E0585 shall be covered for the same indications as in (1)(a)(B)(i);

(iii) An E0565 or E0572 compressor and filtered nebulizer (A7006) may be covered when it is medically necessary and appropriate to administer pentamidine to a client with HIV, pneumocystosis, or complications of organ transplants;

(i) A small volume ultrasonic nebulizer (E0574) and related accessories may be covered when it is medically necessary and appropriate to administer treprostinil inhalation solution (J7686) to a client with pulmonary hypertension only;

(D) Controlled dose inhalation drug delivery system:

(i) A controlled dose inhalation drug delivery system (K0730) may be covered when it is medically necessary and appropriate to administer iloprost (Q4074) to clients with pulmonary hypertension only;

(E) Large volume ultrasonic nebulizer:

(i) A large volume ultrasonic nebulizer (E0575) offers no proven clinical advantage over a pneumatic compressor and nebulizer and will be reviewed on a case-by-case basis to determine if medically necessary and appropriate for use;

(F) The Division shall consider other uses of compressors/generators individually on a case-by-case basis to determine their medical appropriateness;

(b) Accessories:

(A) A large volume pneumatic nebulizer (E0580) and water or saline (A4217 or A7018) are not separately payable and may not be separately billed when used for clients with rented home oxygen equipment;

(B) The Division does not cover use of a large volume nebulizer, related compressor/generator, and water or saline when used predominately to provide room humidification;

(C) A prefilled disposable large volume nebulizer (A7008) is considered a convenience item. A non-disposable unfilled nebulizer (A7007, A7017, or E0585) filled with water or saline (A4217 or A7018) by the client or caregiver is an acceptable alternative to the large volume nebulizer when used as indicated in (1)(a)(B)(i) of this rule;

(D) Kits and concentrates for use in cleaning respiratory equipment are not covered;

(E) Accessories used in conjunction with ultrasonic nebulizers coded E0574 shall be billed on separate claim lines. The dome and mouthpiece shall be billed with code A7016. Other accessories shall be billed with code A9999. When code A9999 is used, the claim must clearly describe the type and quantity of accessories provided;

(F) Accessories are separately payable if the related aerosol compressor and the individual accessories are medically appropriate. The following table lists each covered compressor/generator and its covered accessories. Other compressor/generator/accessory combinations are not covered;

(G) Compressor/Generator (Related Accessories): E0565 (A4619, A7006, A7010, A7012, A7013, A7014, A7015, A7017, A7525, E1372); E0570 (A7003, A7004, A7005, A7006, A7013, A7015, A7525); E0572 (A7006, A7007, A7014, A7017); E0574 (A7013, A7014, A7016); E0585 (A4619, A7006, A7010, A7012, A7013, A7014, A7015, A7525); K0730 (A7005);

(H) This array of accessories represents all possible combinations, but it may not be appropriate to bill any or all of them for one device;

(I) Table 122-0204-1 lists the usual maximum frequency of replacement for accessories. The Division shall not cover claims for more than the usual maximum replacement amount unless the request has been prior approved by the Division before dispensing. The provider shall submit requests for more than the usual maximum replacement amount to the Division for review.

(2) Coding guidelines:

(a) Accessories:

(A) Codes A7003, A7005, and A7006 include the lid, jar, baffles, tubing, T-piece, and mouthpiece. In addition, code A7006 includes a filter;

(B) Code A7004 includes only the lid, jar, and baffles;

(C) Code A7012 describes a device to collect water condensation, which is placed in line with the corrugated tubing, used with a large volume nebulizer;

(D) Code A7016 describes the dome and mouthpiece containing the aerosolization mechanism for an ultrasonic/electronic nebulizer system;

(E) Code E0585 is used when a heavy-duty aerosol compressor (E0565), durable bottle type large volume nebulizer (A7017), and immersion heater (E1372) are provided at the same time. If all three items are not provided initially, the separate codes for the components would be used for billing;

(F) Code A7007 or A7017 is billed for a durable, bottle type nebulizer when it is used with an E0572 compressor or a separately billed E0565 compressor;

(G) Code A7007 or A7017 may not be separately billed when an E0585 system is also being billed. Code E0580 (Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flow meter) describes the same piece of equipment as A7017 but shall only be billed when this type of nebulizer is used with a client-owned oxygen system.

(b) Equipment:

(A) In this policy, nebulization of inhalation solutions is accomplished by two types of devices. Pneumatic compressor nebulizers achieve nebulization of liquid by means of air flow. Ultrasonic or electronic nebulizers produce nebulization of liquid by means of a vibrating mechanism;

(B) Code E0565 describes an aerosol compressor, which can be set for pressures above 30 psi at a flow of 6-8 L/m and is capable of continuous operation;

(C) A nebulizer with compressor (E0570) is an aerosol compressor, which delivers a fixed, low pressure and is used with a small volume nebulizer. It may be AC powered; DC powered or both;

(D) A light duty adjustable pressure compressor (E0572) is a pneumatic aerosol compressor that can be set for pressures above 30 psi at a flow of 6-8 L/m but is capable only of intermittent operation;

(E) Code E0574 describes an ultrasonic/electronic generator used with a small volume chamber for medication delivery. Aerosolization of the inhalation solution occurs in a nebulization chamber by means of a vibrating mechanism such as (not all inclusive) a vibrating disk, pizo-electric device, or vibrating mesh;

(F) Code E0575 describes a large volume ultrasonic nebulizer system that is used for medication and humidification delivery, and which is capable of continuous operation;

(G) Code K0730 describes a controlled dose inhalation drug delivery system. Aerosol is delivered in pulses during the inspiration. The duration of each pulse is adapted according to the breathing pattern.

(3) Documentation requirements:

(a) When billing for an item in Table 122-0204, medical records shall corroborate that all criteria in this rule are met;

(b) When billing for quantities of supplies greater than those described in Table 122-0204-1 as the usual maximum amounts, there shall be clear documentation in the client’s medical records corroborating the medical appropriateness of the current use;

(c) When a compressor/generator is dispensed for other uses, supporting documentation that justifies the medical appropriateness shall be on file with the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provider;

(d) The DMEPOS provider shall maintain these medical records and make them available to the Division upon request.

(4) Table 122-0204-1.

(5) Table 122-0204-2.

[ED. NOTE: Table referenced is available from the agency.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 39-2024, minor correction filed 01/25/2024, effective 01/25/2024
DMAP 4-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0205 Respiratory Assist Devices

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover the initial three (3) month trial period of a respiratory assist device (RAD) for clients who are diagnosed with one of the following clinical disorders: Restrictive Thoracic Disorders, Severe Chronic Obstructive Pulmonary Disease (COPD), Central Sleep Apnea (CSA), Complex Sleep Apnea (CompSA), or Hypoventilation Syndrome; and when the criteria for each specific clinical disorder and the following guidelines are met:

(2) As referenced in this policy, non-invasive positive pressure respiratory assistance (NPPRA) is the administration of positive air pressure, using a nasal and/or oral mask interface which creates a seal, avoiding the use of more invasive airway access (e.g., tracheostomy).

(3) Indications and Coverage — General:

(a) The "treating practitioner" must be one who is qualified by virtue of experience and training in non-invasive respiratory assistance, to order and monitor the use of respiratory assist devices (RAD);

(b) For the purpose of this policy, polysomnographic studies must be performed in a sleep study laboratory, and not in the home or in a mobile facility. The sleep study laboratory must comply with all applicable state and federal regulatory requirements;

(c) For the purpose of this policy, arterial blood gas, sleep oximetry and polysomnographic studies may not be performed by a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provider. For purposes of this policy's coverage and payment guidelines, a DMEPOS provider is not considered a qualified provider or supplier of these tests;

(4) Indications and Coverage — Coverage criteria for RAD devices per diagnosed condition:

(a) Restrictive Thoracic Disorders:

(A) A bilevel device without backup rate (E0470) or a respiratory assist device with a backup rate (E0471) is covered when criteria i-iii are met:

(i) There is documentation in the client’s medical record of a neuromuscular disease (for example, amyotrophic lateral sclerosis (ALS), or a severe thoracic cage abnormality (for example, post thoracoplasty for TB);

(ii) One of the following:

(I) An arterial blood gas PaCO2, done while awake and breathing the client’s prescribed FIO2 is greater than or equal to 45 mm Hg, or

(II) Sleep oximetry demonstrates oxygen saturation less than or equal to 88 percent for greater than or equal to five (5) minutes of nocturnal recording time (minimum recording time of two (2) hours), done while breathing the client’s prescribed recommended FIO2, or

(III) For a neuromuscular disease (only), either maximal inspiratory pressure is less than 60 cm H@O or forced vital capacity is less than 50 percent predicted;

(iii) Chronic obstructive pulmonary disease does not contribute significantly to the client’s pulmonary limitation.

(B) If all of the above criteria are met, either an E0470 or an E0471 device will be covered for the first three months of therapy.

(b) Severe COPD:

(A) An E0470 device is covered if criteria i - iii are met:

(i) An arterial blood gas PaCO2, done while awake and breathing the client’s prescribed FIO2, is greater than or equal to 52 mm Hg.

(ii) Sleep oximetry demonstrates oxygen saturation less than or equal to 88 percent for greater than or equal to a cumulative five (5) minutes of nocturnal recording time (minimum recording time of two (2) hours), done while breathing oxygen at two (2) LPM or the client’s prescribed FIO2 (whichever is higher).

(iii) Prior to initiating therapy, sleep apnea and treatment with a continuous positive airway pressure device (CPAP) has been considered and ruled out. (Note: Formal sleep testing is not required if there is sufficient information in the medical record to demonstrate that the beneficiary does not suffer from some form of sleep apnea (Obstructive Sleep Apnea (OSA), CSA and/or CompSA) as the predominant cause of awake hypercapnia or nocturnal arterial oxygen desaturation).

(B) For severe COPD clients who qualified for an E0470 device, an E0471 started any time after a period of initial use of an E0470 device is covered if both criteria i and ii are met:

(i) An arterial blood gas PaCO2, done while awake and breathing the client’s prescribed FIO2, shows that the client’s PaCO2 worsens greater than or equal to seven (7) mm Hg compared to the original result from criterion (A)(i), (above).

(ii) A facility-based PSG demonstrates oxygen saturation less than or equal to 88 percent for greater than or equal to a cumulative five (5) minutes of nocturnal recording time (minimum recording time of two (2) hours) while using an E0470 device that is not caused by obstructive upper airway events – i.e., AHI less than five (5).

(C) For severe COPD clients who qualified for an E0470 device, an E0471 device will be covered if, at a time no sooner than 61 days after initial issue of the E0470 device, both of the following criteria i and ii are met:

(i) An arterial blood gas PaCO2 is done while awake and breathing the client’s prescribed FIO2, still remains greater than or equal to 52 mm Hg.

(ii) Sleep oximetry while breathing with the E0470 device, demonstrates oxygen saturation less than or equal to 88 percent for greater than or equal to a cumulative five (5) minutes of nocturnal recording time (minimum recording time of two (2) hours), done while breathing oxygen at two (2) LPM or the client’s prescribed FIO2 [whichever is higher].

(A) An E0470 or E0471 device is covered when, prior to initiating therapy, a complete facility-based, attended PSG is performed documenting the following (i and ii):

(i) Diagnosis of CSA or CompSA; and

(ii) Significant improvement of the sleep-associated hypoventilation with the use of an E0470 or E0471 device on the settings that will be prescribed for initial use at home, while breathing the client’s prescribed FIO2.

(B) If all of the above criteria are met, either an E0470 or an E0471 device will be covered for the first three (3) months of therapy.

(d) Hypoventilation Syndrome

(A) An E0470 device is covered if both criteria i and ii and either criteria iii or iv are met:

(i) Initial arterial blood gas PaCO2, done while awake and breathing the client’s prescribed FIO2, is greater than or equal to 45 mm Hg;

(ii) Spirometry shows an FEV1/FVC greater than or equal to 70 percent;

(iii) Arterial blood gas PaCO2, done during sleep or immediately upon awakening, and breathing the client’s prescribed FIO2, shows the client's PaCO2 worsened greater than or equal to seven (7) mm Hg compared to the original result in criterion (A)(i) (above);

(iv) Facility-based PSG or HST demonstrates oxygen saturation less than or equal to 88 percent for greater than or equal to five (5) minutes of nocturnal recording time (minimum recording time of two (2) hours) that is not caused by obstructive upper airway events – i.e., AHI less than five (5).

(B) An E0471 device is covered for a client with hypoventilation syndrome if both criteria i, ii, and either criteria iii or iv are met:

(i) A covered E0470 device is being used;

(ii) Spirometry shows an FEV1/FVC greater than or equal to 70 percent;

(iii) Arterial blood gas PaCO2, done while awake, and breathing the client’s prescribed FIO2, shows that the client’s PaCO2 worsens greater than or equal to seven (7) mm Hg compared to the arterial blood gas (ABG) result performed to qualify the client for the E0470 device;

(iv) Facility-based PSG or HST demonstrates oxygen saturation less than or equal 88 percent for greater than or equal to five (5) minutes of nocturnal recording time (minimum recording time of two (2) hours) that is not caused by obstructive upper airway events – i.e., AHI less than five (5) while using an E0470 device.

(5) Continued Coverage: Prior authorization (PA) is required for ongoing rental of a RAD device beyond the third (3rd) month and may be covered when the conditions for continued coverage in this rule are met. Submit the following documentation with request for authorization prior to the (4th) fourth month date of service:

(a) Evaluation completed by the prescribing practitioner no sooner than sixty-one (61) days after initiating use of the RAD device, stating the client is compliantly using the RAD device an average of four (4) hours per twenty-four (24) hour period and the client is benefiting from its use; and

(b) Objective evidence of adherence to use of the RAD device, including a summary of RAD compliance report through a direct download of usage.

(6) Accessories:

(a) Either a non-heated (E0561) or heated (E0562) humidifier is covered and reimbursed separately when ordered by the treating practitioner for use with a covered RAD device. No PA is required;

(b) For replacement of accessories beyond initial issue:

(A) Suppliers are required to verify the RAD device is still in use;

(B) Regardless of utilization, a supplier must not dispense more than a three (3) month quantity of accessories;

(A) A4604 — 1 per 3 months;

(B) A7027 — 1 per 3 months;

(D) A7029 — 2 per month;

(E) A7030 — 1 per 3 months;

(F) A7031 — 1 per month;

(G) A7032 — 2 per month;

(H) A7033 — 2 per month;

(I) A7034 — 1 per 3 months;

(J) A7035 — 1 per 6 months;

(K) A7036 — 1 per 6 months;

(L) A7037 — 1 per 3 months;

(M) A7038 — 2 per month;

(N) A7039 — 1 per 6 months;

(O) A7046 — 1 per 6 months.

(7) Reimbursement:

(a) Rental charges apply toward purchase;

(b) Capped rental period begins the date the equipment is dispensed and shall not extend beyond the thirteenth (13th) consecutive month;

(c) Equipment is considered purchased upon completion of the capped rental period, after the Division fee schedule purchase price is met, or when the actual charge from the provider is met, whichever is less;

(d) When the RAD is not being used as prescribed or client is non-compliant with its use, the DMEPOS provider shall stop billing for the continued rental of the equipment and the purchase of related accessories and supplies.

(8) Documentation:

(a) The following documentation must be submitted with the request for PA and the original kept on file with the DMEPOS provider:

(A) An order for all equipment and accessories including the client's diagnosis, an ICD-10-CM code signed and dated by the treating practitioner;

(B) Summary of events from the polysomnogram;

(D) Sleep oximetry results, if required under the indications and coverage section;

(E) Treating practitioner statement regarding medical symptoms characteristic of sleep-associated hypoventilation, including, but not limited to daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, and dyspnea;

(F) Other treatments that have been tried and failed. To be submitted in addition to the above at the fourth (4th) month review;

(b) Clients currently using BiPapS and BiPap ST are not subject to the new criteria.

(9) Table 122-0205-1, Procedure Codes.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00

Or. Admin. R. 410-122-0206 Intermittent Positive Pressure Breathing

E0500, IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source the Division will rent. Covered if medically appropriate for the following indications:

(1) Clients at risk of respiratory failure because of decreased respiratory function secondary to kyphoscoliosis or neuromuscular disorders.

(2) Clients with severe bronchospasm or exacerbated chronic obstructive pulmonary disease (COPD) who fail to respond to standard therapy.

(3) The management of atelectasis that has not improved with simple therapy.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0207 Respiratory Supplies

Table 122-0207.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0208 Suction Pumps

(1) Indications and Limitations of Coverage:

(a) Use of a home model respiratory suction pump may be covered for a client who has difficulty raising and clearing secretions secondary to:

(A) Cancer or surgery of the throat or mouth; or

(B) Dysfunction of the swallowing muscles; or

(D) Tracheostomy; or

(E) Neuromuscular conditions;

(b) When a respiratory suction pump (E0600) is covered, tracheal suction catheters are separately payable supplies. In most cases, in the home setting, sterile catheters are medically appropriate only for tracheostomy suctioning. Three suction catheters per day are covered for medically appropriate tracheostomy suctioning, unless additional documentation is provided. When a tracheal suction catheter is used in the oropharynx, which is not sterile, the catheter can be reused if properly cleansed and/or disinfected. In this situation, the medical appropriateness for more than three catheters per week requires additional documentation;

(c) Sterile saline solution (A4216, A4217) may be covered and separately payable when used to clear a suction catheter after tracheostomy suctioning. It is not usually medically appropriate for oropharyngeal suctioning. Saline used for tracheal lavage is not covered;

(d) Supplies (A4628) are covered and are separately payable when they are medically appropriate and used with a medically appropriate suction pump (E0600) in a covered setting;

(e) When a suction pump (E0600) is used for tracheal suctioning, other supplies (e.g., cups, basins, gloves, solutions, etc.) are included in the tracheal care kit code, A4625–(see OAR 410-122-0209 for details). When a suction pump is used for oropharyngeal suctioning, these other supplies are not medically appropriate;

(f) The suction device must be appropriate for home use without technical or professional supervision. Those using the suction apparatus must be sufficiently trained to adequately, appropriately and safely use the device.

(2) A client’s medical record must reflect the need for the supplies dispensed and billed. The medical record must be kept on file by the durable medical equipment (DME) provider and made available to the Division of Medical Assistance Programs (Division) upon request.

(3) A portable or stationary home model respiratory suction pump (E0600) is an electric aspirator designed for oropharyngeal and tracheal suction.

(4) A portable or stationary home model gastric suction pump (E2000) is an electric aspirator designed to remove gastrointestinal secretions.

(5) A tracheal suction catheter is a long, flexible catheter.

(6) An oropharyngeal catheter is a short, rigid (usually) plastic catheter of durable construction.

(7) Code E0600 must not be used for a suction pump used with gastrointestinal tubes.

(8) Code E2000 must be used for a suction pump used with gastrointestinal tubes.

(9) Providers should contact the Medicare Pricing, Data Analysis and Coding (PDAC) contractor for guidance on the correct coding of these items.

(10) When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, there must be clear documentation in the client’s medical records corroborating the medical appropriateness for the higher utilization. The Division may request copies of the client’s medical records that corroborate the order and any additional documentation that pertains to the medical appropriateness of items and quantities billed.

(11) Table 122-0208, Suction Pumps.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 76-2003, f. & cert. ef. 10-1-03
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0209 Tracheostomy Care Supplies

(1) Indications and Coverage: For a client following an open surgical tracheostomy that has been open or is expected to remain open for at least three months:

(a) Standard tracheostomy supplies, including tracheostomy tubes (A7520, A7521), do not require prior authorization;

(b) Custom/Specialized tracheostomy tubes must be a device that requires the manufacturer to complete substantive customization or modification for a specific individual’s medical need;

(c) Custom/Specialized tracheostomy tubes require prior authorization and shall be approved with clinical documentation supporting the medical appropriateness and a statement from the prescribing practitioner explaining why a standard or off-the-shelf tracheostomy tube will not meet the client’s medical needs.

(2) Documentation:

(a) A prescription for tracheal equipment that is signed by the prescribing practitioner shall be kept on file by the DMEPOS provider. The prescribing practitioner’s records shall contain information that supports the medical appropriateness of the item ordered;

(b) Custom/Specialized tracheostomy tubes require an assessment every six months indicating a standard tracheostomy tube does not currently meet the medical needs of the client. Documentation shall be submitted to the Division at the time of request.

(3) Billing:

(a) Custom/Specialized tracheostomy tubes shall be billed using the correct HCPCS code and modifier 22;

(b) Custom/Specialized tracheostomy tubes shall be reimbursed following the payment methodology outlined in OAR 410-122-0186 for manually priced items.

(4) Procedure Codes – Table 122-0209.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 9-2015, f. 2-26-15, cert. ef. 3-1-15
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 10-1992, f. & cert. ef. 4-1-92

Or. Admin. R. 410-122-0210 Ventilators

(1) Indications and limitations of coverage:

(a) Mechanical ventilatory support may be provided to a client for the purpose of life support during therapeutic support of suboptimal cardiopulmonary function, or therapeutic support of chronic ventilatory failure;

(b) A ventilator may be covered by the Division for treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. This includes both positive and negative pressure types;

(c) A ventilator for pediatric home ventilator management may be covered on a case-by-case basis based on medical appropriateness, evidence-based medicine and best health practices.

(2) Primary Ventilators:

(a) A primary ventilator may be covered if supporting documentation indicates:

(A) A client is unable to be weaned from the ventilator or is unable to be weaned from use at night; or

(B) Alternate means of ventilation were used without success; or

(b) E0465, E0466 or E0472 may be covered if:

(A) A client has no respiratory drive either due to paralysis of the diaphragm or a central brain dysfunction; or

(B) A client has a stable, chronic condition with no orders to wean from the ventilator; or

(C) A client has had a trial with blood gases and has no signs or symptoms of shortness of breath or increased work of breathing; or

(D) A client has uncompromised lung disease;

(A) A client has chronic lung disease where volume ventilation may further damage lung tissue; or

(B) A client has a compromised airway or musculature and has respiratory drive and a desire to breathe; or

(D) A client has compromised respiratory muscles from muscular dystrophies or increased resistance from airway anomalies or scoliosis conditions.

(3) Secondary Ventilators:

(a) A secondary ventilator, identical or similar to the primary ventilator, may be covered when necessary to serve a different medical need of a client;

(b) For example (not all-inclusive), a secondary ventilator may be covered when:

(A) A client requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and needs a different type of ventilator (e.g., positive pressure respiratory assist device with a nasal mask) during the rest of the day; or

(B) A client is confined to a wheelchair who requires a ventilator permanently mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed.

(4) Reimbursement Rates:

(a) Reimbursement rates for ventilators are calculated based on consideration that break down or malfunction of a ventilator could result in immediate life-threatening consequences for a client. Therefore, ventilators are reimbursed on a monthly rental payment for as long as the equipment is medically appropriate;

(b) Payment includes:

(A) The durable medical equipment (DME) provider ensuring that an appropriate and acceptable contingency plan to address emergency situations or mechanical failures of the primary ventilator is in place. This could mean that the provider furnishes a backup ventilator;

(B) Any equipment, supplies, services, including respiratory therapy (respiratory care) services, routine maintenance and training necessary for the effective use of the ventilator;

(c) Secondary Ventilators: The maximum reimbursement rate is one-half the maximum allowable fee for the primary ventilator.

(5) The client must have a telephone or reasonable access to one.

(6) A backup ventilator provided as a precautionary measure for emergency situations in which the primary ventilator malfunctions is not separately payable by the Division.

(7) Prior authorization (PA):

(a) PA is not required when E0465, E0466 or E0472 is dispensed as the primary ventilator. The provider is responsible to ensure all rule requirements are met;

(b) PA is required for a secondary ventilator:

(A) Payment authorization is required prior to the second date of service and before submitting claims. See Oregon Administrative Rule (OAR) 410-120-0000 (General Rules);

(B) Payment authorization shall be given once all required documentation has been received and any other applicable rules and criteria have been met; and

(8) Documentation Requirements:

(a) For services requiring payment authorization or PA, submit documentation that supports coverage criteria in this rule are met;

(b) Documentation that coverage criteria have been met must be present in the client’s medical records, kept on file with the DME provider and made available to the Division on request. Table 122-0210

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 5-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 76-2004, f. 9-30-04, cert. ef. 10-1-04
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 10-1992, f. & cert. ef. 4-1-92

Or. Admin. R. 410-122-0211 Cough Stimulating Device

(1) Indications and Limitations of Coverage and Medical Appropriateness: The Division may cover a cough stimulating device, alternating positive and negative airway pressure, for a client who meets the following criteria:

(a) The client has been diagnosed with a neuromuscular disease as identified by one of the following diagnosis codes:

(A) Late effects of acute poliomyelitis;

(B) Cystic fibrosis;

(D) Multiple sclerosis — quadriplegia and quadriparesis;

(E) Myoneural disorders;

(F) Disorders of diaphragm;

(G) Fracture of vertebral column, cervical, or dorsal (thoracic);

(H) Late effect of spinal cord injury;

(I) Late effect of injury to a nerve root or roots, spinal plexus or plexuses and other nerves of trunk;

(J) Spinal cord injury without evidence of spinal bone injury, cervical or dorsal (thoracic); and

(b) Standard treatment such as chest physiotherapy (e.g., chest percussion and postural drainage, etc.) has been tried and documentation supports why these modalities were not successful in adequately mobilizing retained secretions; or

(c) Standard treatment such as chest physiotherapy (e.g., chest percussion and postural drainage, etc.) is contraindicated and documentation supports why these modalities were ruled out; and

(d) The condition is causing a significant impairment of chest wall or diaphragmatic movement, such that it results in an inability to clear retained secretions.

(2) Prior Authorization (PA):

(a) PA is required for the cough stimulating device (E0482);

(b) Submit specific documentation from the treating practitioner that supports coverage criteria in this rule are met and may include, but is not limited to, evidence of any of the following:

(A) Poor, ineffective cough;

(B) Compromised respiratory muscles from muscular dystrophies or scoliosis;

(D) Frequent hospitalizations or emergency department/urgent care visits due to pneumonias.

(3) Reimbursement:

(a) The Division shall purchase or rent on a monthly basis (limited to the lowest cost alternative);

(b) The cough stimulating device (E0482) is considered purchased after no more than ten (10) months of rent;

(c) The Division may cover replacement of the interface (A7020) once every six (6) months with continued use of a client-owned cough stimulating device.

(4) Payment includes:

(a) The rental fee includes all equipment, supplies (including the interface), services, routine maintenance, and necessary training for the effective use and operation of the device;

(b) The initial purchase fee includes all equipment, supplies (including the interface), services, and necessary training for the effective use and operation of the device.

(5) E0482 may be covered for a client residing in a nursing facility.

(6) Documentation Requirements:

(a) For services requiring prior authorization, submit documentation that supports coverage criteria in this rule are met;

(b) Documentation and medical records to support the client meets all criteria and conditions of coverage in this rule must be kept on file with the DMEPOS provider and shall be available to the Division upon request.

(7) Procedure Codes:

(a) E0482- Cough stimulating device, alternating positive and negative airway pressure – PA

(b) A7020- Interface for cough stimulating device, includes all components, replacement only.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 14-2016, f. 3-22-16, cert. ef. 4-1-16
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09

Or. Admin. R. 410-122-0220 Pacemaker Monitor

(1) E0610 — Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems:

(a) The Division will purchase;

(b) Also covered for payment by the Division when client is a resident of a nursing facility.

(2) E0615 — Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems:

(a) The Division will purchase;

(b) Also covered for payment by the Division when client is a resident of a nursing facility.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
HR 9-1993, f. & cert. ef. 4-1-93
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0240 Apnea Monitors for Infants

(1) Indications and limitations of coverage and medical appropriateness:

(a) For infants less than twelve (12) months of age with documented apnea, or who have known risk factors for life-threatening apnea, the Division may cover home apnea monitors and related supplies for any of the following indications:

(A) Up to three (3) months for:

(i) Apnea of prematurity: Sudden cessation of breathing that lasts for at least 20 seconds, is accompanied by bradycardia (heart rate less than 80 beats per minute), or is accompanied by oxygen desaturation (O2 saturation less than 90 percent or cyanosis) in an infant younger than 37 weeks gestational age;

(ii) Apparent life-threatening event (ALTE): An episode that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging;

(iii) Documented gastroesophageal reflux disease (GERD) that results in apnea, bradycardia, or oxygen desaturation;

(iv) Documented prolonged apnea of greater than 20 seconds in duration;

(v) Documented apnea accompanied by bradycardia to less than 80 beats per minute;

(vi) Documented apnea accompanied by oxygen desaturation (below 90 percent), cyanosis, or pallor;

(vii) Documented apnea accompanied by marked hypotonia;

(viii) When off medication for bradycardia previously treated with caffeine, theophylline, or similar agents;

(B) Upon discharge from an acute care facility for up to one month post-diagnosis for diagnosis of pertussis with positive cultures;

(C) As the later sibling of an infant who died of Sudden Infant Death Syndrome (SIDS), until the later sibling is one (1) month older than the age at which the earlier sibling died and remains event-free;

(D) On a case-by-case basis for:

(i) Infants with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise;

(ii) Infants with neurologic or metabolic disorders affecting respiratory control;

(iii) Infants with chronic lung disease (bronchopulmonary dysplasia), especially those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation;

(b) Infant apnea monitors are usually considered medically appropriate for no longer than approximately three months except for specific conditions listed above;

(c) The rental fee includes all training, instruction, assistance, 24-hour on-call support, and any other needed services for effective use of the apnea monitor, including cardiopulmonary resuscitation training. The durable medical equipment prosthetics orthotics and supplies (DMEPOS) provider is responsible for ensuring delivery of these services;

(d) The Division may cover related supplies necessary for the effective functioning of the apnea monitor for a three (3) month period based on the following limitations:

(A) Electrodes, per pair (A4556) — 3 units;

(B) Lead wires, per pair (A4557) — 2 units;

(D) Belts (A4649) — 2 units;

(e) The cost of apnea monitor rental includes the cost of cables;

(f) The Division does not cover apnea monitors with memory recording (E0619) when the attending practitioner is monitoring the infant with ongoing sleep studies and pneumograms.

(2) Coding guidelines: For billing purposes, use diagnosis code 798.0, Sudden Infant Death Syndrome (SIDS), for later siblings of infants who died of SIDS.

(3) Documentation requirements: Submit the following information with the prior authorization (PA) request:

(a) Documentation (medical records including hospital records, sleep studies, practitioner’s progress notes, practitioner-interpreted report from an apnea monitor with memory recording, etc.) of the episode or episodes that led to the diagnosis;

(b) An order from the practitioner who diagnosed the infant as having clinically significant apnea or known risk factors for life-threatening apnea. The practioner’s order shall indicate the specific type of apnea monitor (with or without recording feature) and detailed information about the type and quantity of related supplies needed;

(c) For an apnea monitor with recording feature (E0619), submit documentation that supports why an apnea monitor without recording feature (E0618) is not adequate to meet the medical need;

(d) When dispensing and billing for an item in Table 122-0240, the provider shall ensure that documentation corroborates that all criteria in this rule are met;

(e) The DMEPOS provider shall maintain documentation and make it available to the Division upon request.

(4) Table 122-0240.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 6-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 60-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0250 Breast Pumps

(1) Indications and limitations of coverage and medical appropriateness:

(a) In accordance with Prioritized List of Health Services Breastfeeding Support and Supplies Guideline Note, the Division may cover a breast pump and supplies for postpartum women when a pump is necessary to establish or maintain milk production in order to maximize availability of breast milk to the baby;

(b) For cases in which there is a medical indication for breast pumps, the pumps shall be supplied whenever possible within 24 hours to allow for continued milk production;

(c) The client or caregiver shall receive instruction from the supplier in the proper use and care of the breast pump within 48 hours of receiving the equipment;

(d) The rental of a hospital grade breast pump (E0604) may be covered for up to three (3) months when prescribed for use in the home;

(e) A breast pump shall not be provided until a need is determined following birth;

(f) A breast pump shall not be provided if it is known that mother is using a substance that is contraindicated while breastfeeding and does not plan to stop its use;

(g) Replacement supplies may be covered when medically necessary and for the continued operation of the breast pump (E0602, E0603, E0604);

(A) Reimbursement of medically necessary replacement supplies are limited to replacement tubing, replacement adapter, replacement cap for breast pump bottle, replacement breast shield and protector, replacement polycarbonate bottle, replacement locking ring, replacement valve, and a disposable collection and storage bag for breast milk (any size, any type);

(B) The following represents the usual number of supplies expected to be medically appropriate; however, the quantity and frequency of replacement supplies shall be determined by the treating practitioner:

(i) A4281 – 2 units per year;

(ii) A4282 – 2 units per year;

(iii) A4283 – 2 units per year;

(iv) A4284 – 2 sets per year;

(v) A4285 – 2 units per year;

(vi) A4286 – 2 units per year;

(vii) A4287 – 186 units per month;

(viii) A4288 – 2 units per year.

(2) Prior Authorization (PA): A PA is obtained from the same authorizing authority as specified in OAR 410-122-0040. PA is required for the following:

(a) Replacement of the breast pump due to loss, theft, or irreparable damage in accordance with OAR 410-122-0184;

(b) Replacement supplies not identified in this rule;

(3) The following services are not considered medically necessary:

(a) Accessories not necessary for the operation of a breast pump (for example, travel bags, nursing bras, bra pads, breast feeding pillows, etc.);

(b) An electric breast pump for the comfort and convenience of the mother;

(d) Replacement parts covered under the manufacturer’s and/or supplier’s warranty.

(4) Reimbursement:

(a) Reimbursement for the purchase of a single-user electric breast pump (E0603) includes all parts and supplies necessary for the operation of the electric pump;

(b) Reimbursement for the purchase of a manual breast pump (E0602) includes all parts and supplies necessary for the operation of the manual pump;

(c) Reimbursement for the first month’s rental of a hospital grade breast pump (E0604) includes all parts and supplies necessary for the operation of the hospital grade pump;

(d) Replacement supplies, other than breast shields, are not reimbursable at the time of purchase or rental;

(e) Rental charges apply to purchase;

(f) Reimbursement is limited to the purchase of one (1) breast pump per pregnancy;

(5) Documentation:

(a) For services requiring prior authorization, submit documentation that supports coverage criteria in this rule are met;

(6) Procedure Codes:

(a) E0602 — Breast pump, manual, any type — purchase only;

(b) E0603 — Breast pump, electric (AC and/or DC), any type — purchase only;

(d) A4281 — Tubing for breast pump, replacement;

(e) A4282 — Adapter for breast pump, replacement;

(f) A4283 — Cap for breast pump bottle, replacement;

(g) A4284 — Breast shield and splash protector for use with breast pump, replacement;

(h) A4285 — Polycarbonate bottle for use with breast pump, replacement;

(i) A4286 — Locking ring for breast pump, replacement;

(j) A4287 — Disposable collection and storage bag for breast milk, any size, any type;

(k) A4288 — Valve for breast pump, replacement.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 20-2026, amend filed 06/03/2026, effective 06/03/2026
DMAP 95-2025, temporary amend filed 12/26/2025, effective 12/26/2025 through 06/23/2026
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 17-1996, f. & cert. ef. 8-1-96
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92

Or. Admin. R. 410-122-0260 Home Uterine Monitoring

(1) Home uterine monitoring (S9001) requires prior authorization (PA) and may be approved for the following conditions:

(a) Pre-term labor with one or more of the following complications:

(A) Incompetent cervix;

(B) Cervical cerclage;

(D) Anomalies of the uterus;

(E) History of cone biopsy;

(F) Cervical dilation or effacement;

(G) Unknown etiology.

(b) History of pre-term labor and delivery;

(2) Uterine monitoring will only be approved for the above conditions between the 24th and through the completion of the 36th week of pregnancy.

(3) The Division will provide coverage for rental only. The allowable rental fee for the uterine monitor includes all equipment, supplies, services, and nursing visits necessary for the effective use of the monitor. This does not include medications or prescribing practitioner’s professional services.

(4) The client must have landline telephone or reasonable access to one. The Division will not be responsible for providing the landline telephone or landline access.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 61-2014, f. 10-3-14, cert. ef. 10-7-14
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0280 Heating/Cooling Accessories

Procedure Codes for Heating/Cooling Accessories: Table 122-0280.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 9-1993, f. & cert. ef. 4-1-93
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0300 Light Therapy

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover home phototherapy when medically appropriate and for the following conditions:

(a) For a term or near-term infant whose elevated bilirubin is not due to a primary hepatic disorder or other hemolytic disorder that requires inpatient care and the American Academy of Pediatrics Clinical Practice Guidelines for management of hyperbilirubinemia with phototherapy are met; the Practice Guidelines are available at https://publications.aap.org/pediatrics/article/150/3/e2022058859/188726/Clinical-Practice-Guideline-Revision-Management-of?autologincheck=redirected

(b) For severe inflammatory skin conditions identified in the Prioritized List of Health Services Severe Inflammatory Skin Disease Guideline Note.

(2) Prior Authorization (PA):

(a) Ultraviolet light therapy systems (E0691, E0692, E0693, E0694);

(b) Refer to the Prioritized List of Health Services Severe Inflammatory Skin Disease Guideline Note for coverage guidelines.

(3) Reimbursement:

(a) Reimbursement for the monthly rental of a phototherapy light (E0202) includes supplies, instruction, training, and twenty-four (24) hour on-call service necessary for the operation and effective use of the equipment;

(b) Reimbursement for the monthly rental or purchase of the ultraviolet light therapy systems includes supplies, instruction, and training necessary for the operation and effective use of the equipment;

(4) Documentation Requirements:

(a) For services that require PA: Submit documentation for review that supports conditions of coverage as specified in this rule are met;

(b) Documentation and medical records to support the client meets all criteria and conditions of coverage in this rule must be kept on file with the DMEPOS provider and shall be made available to the Division upon request.

(5) Procedure Codes:

(a) E0202 — Phototherapy (bilirubin) light with photometer

(b) E0691 — Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less

(d) E0693 — Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel

(e) E0694 — Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection

(f) A4633 — Replacement bulb/lamp for ultraviolet light therapy system, each

(6) Table 122-0300 Light Therapy.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 20-2026, amend filed 06/03/2026, effective 06/03/2026
DMAP 95-2025, temporary amend filed 12/26/2025, effective 12/26/2025 through 06/23/2026
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 7-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0320 Manual Wheelchair Base

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover a manual wheelchair when conditions of coverage in OAR 410-122-0080 and all of the following criteria are met:

(A) The client has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in or out of the home. MRADLs include but are not limited to tasks such as eating, toileting, grooming, dressing, and bathing. A mobility limitation is one that:

(i) Prevents the client from accomplishing an MRADL entirely;

(ii) Places the client at reasonably determined heightened risk of morbidity or mortality secondary to attempts to perform an MRADL; or

(iii) Prevents the client from completing an MRADL within a reasonable time frame.

(B) An appropriately fitted cane or walker cannot sufficiently resolve the client’s mobility limitation;

(C) If the client shall be using the wheelchair in the home, the home provides adequate maneuvering space, maneuvering surfaces, and access between rooms for use of the manual wheelchair that is being requested;

(D) Use of a manual wheelchair shall significantly improve the client’s ability to participate in their MRADLs. For clients with severe cognitive or physical impairments, participation in MRADLs may require the assistance of a caregiver;

(E) The client is willing to use the requested manual wheelchair on a regular basis;

(F) The client has either:

(i) Sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the requested manual wheelchair during a typical day. Proper assessment of upper extremity function shall consider limitations of strength, endurance, range of motion, coordination, presence of pain, and deformity or absence of one or both upper extremities; or

(ii) A caregiver who is available, willing, and able to provide assistance with the wheelchair.

(b) The Division may authorize a manual wheelchair for any of the following situations, only when conditions of coverage as specified in section (1)(a) of this rule are met:

(A) When the wheelchair can be reasonably expected to improve the client’s ability to complete MRADLs by compensating for other limitations in addition to mobility deficits, and the client is compliant with treatment:

(i) Besides MRADLs deficits, when other limitations exist, and these limitations can be ameliorated or compensated sufficiently such that the additional provision of a manual wheelchair may be reasonably expected to significantly improve the client’s ability to perform or obtain assistance to participate in MRADLs, a manual wheelchair may be considered for coverage;

(ii) If the amelioration or compensation requires the client's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial of manual wheelchair coverage if it results in the client continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of a manual wheelchair.

(B) For a purchase request, when a client’s current wheelchair is no longer medically appropriate, or repair and modifications to the wheelchair exceed replacement cost;

(C) When a covered, client-owned wheelchair is in need of repair, the Division may pay for one (1) month’s rental of a wheelchair in accordance with OAR 410-122-0184 Repairs, Maintenance, Replacement, Delivery and Dispensing.

(c) The Division may not reimburse for another wheelchair if the client has a medically appropriate wheelchair, regardless of payer;

(d) If the client shall be using the wheelchair in the home, the home must be able to accommodate and allow for the effective use of the requested wheelchair. The Division does not reimburse for adapting living quarters;

(e) The Division may not cover services or upgrades that primarily allow performance of leisure or recreational activities. Such services include but are not limited to backup wheelchairs, backpacks, accessory bags, awnings, additional positioning equipment if wheelchair meets the same need, custom colors, and wheelchair gloves;

(f) Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair, as well as support services such as delivery, set-up, pick-up and delivery for repairs/modifications, education, ongoing assistance with the use of the wheelchair; and if provided, emergency services;

(g) The Division may cover an adult tilt-in-space wheelchair (E1161) when a client meets all of the following conditions (A-I):

(A) A standard base with a reclining back option will not meet the client’s needs;

(B) Requires assistance with transfers;

(C) The client’s plan of care addresses the need to change position at frequent intervals, and the client is not left in the tilt position most of the time; and

(D) Has one of the following:

(i) High risk of skin breakdown;

(ii) Poor postural control, especially of the head and trunk;

(iii) Hyper/hypotonia;

(iv) Need for frequent changes in position and has poor upright sitting.

(E) The client must have a specialty evaluation, conducted within six (6) months prior to the start of services, that was performed by a licensed/certified medical professional, such as a PT or OT, or treating practitioner who has specific training and experience in rehabilitation wheelchair evaluations and documents the medical necessity for the wheelchair and its special features, including a description of the client's mobility needs within the home and community. The PT, OT, or treating practitioner billing or rendering services must not have a financial relationship with the DMEPOS provider;

(F) Tilt-n-space wheelchairs must be supplied by a DMEPOS provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client;

(G) The ATP must be employed by the provider in a full-time, part-time, or contracted capacity as is acceptable by state law. The ATP, if part-time or contracted, must be under the direct control of the provider;

(H) Documentation must be complete and detailed enough so a third party shall be able to understand the nature of the provider’s ATP involvement, if any, in the evaluation;

(I) The ATP may not conduct the provider evaluation at the time of delivery of the wheelchair to the client’s residence;

(h) One month’s rental for a manual adult tilt-in-space wheelchair (E1161) may be covered for a client residing in a nursing facility when all of the following conditions are met:

(A) The anticipated nursing facility length of stay is thirty (30) days or less;

(B) The conditions of coverage for a manual tilt-in-space wheelchair as described in section (1) (g) (A)-(I) are met;

(C)The client is expected to have an ongoing need for this same wheelchair after discharge from the nursing facility;

(D) Coverage is limited to one month’s rental.

(i) The Division may cover a standard hemi (low seat) wheelchair (K0002) when a client requires a lower seat height (17" to 18") because of short stature or needing assistance to place his feet on the ground for propulsion;

(j) The Division may cover a lightweight wheelchair (K0003) when a client:

(A) Cannot self-propel in a standard wheelchair using arms or legs; and

(B) Can and does self-propel in a lightweight wheelchair.

(k) High-strength lightweight wheelchair (K0004):

(A) The Division may cover a high-strength lightweight wheelchair (K0004) when a client:

(i) Self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair; or

(ii) Requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair and spends at least two (2) hours per day in the wheelchair.

(B) If the expected duration of need is less than three (3) months (e.g., postoperative recovery), a high-strength lightweight wheelchair is rarely medically appropriate.

(l) The Division may cover an ultra-lightweight wheelchair (K0005) when criteria (A) or (B) are met and (C) and (D) are met:

(A) The client must be a full-time manual wheelchair user; or

(B) The client must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001, K0002, K0003 or K0004 manual wheelchair; and

(C) The client must have a specialty evaluation, conducted within six (6) months prior to the start of services, that was performed by a licensed/certified medical professional, such as a PT or OT, or treating practitioner who has specific training and experience in rehabilitation wheelchair evaluations and documents the medical necessity for the wheelchair and its special features, including a description of the client's mobility needs within the home and community. The PT, OT, or treating practitioner billing or rendering services must not have a financial relationship with the DMEPOS provider. Documentation may include what types of activities the client frequently encounters and whether the client is fully independent in the use of the wheelchair. Describe the features of the K0005 base that are needed compared to the K0004 base; and

(D) The wheelchair must be supplied by a DMEPOS provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client;

(m) The Division may cover a heavy-duty wheelchair (K0006) when a client weighs more than 250 pounds or has severe spasticity;

(n) The Division may cover an extra heavy-duty wheelchair (K0007) when a client weighs more than 300 pounds;

(o) For a client residing in a nursing facility, an extra heavy-duty wheelchair (K0007) may only be covered when a client weighs more than 350 pounds;

(p) For more information on coverage criteria regarding repairs and maintenance, see 410-122-0184 Repairs, Maintenance, Replacement and Delivery;

(q) The wheelchair requested must be the most appropriate and least costly alternative that shall meet the client’s medical and functional needs.

(2) Coding Guidelines:

(a) Adult manual wheelchairs (K0001-K0007, K0009, E1161) have a seat width and a seat depth of 15” or greater;

(b) For codes K0001-K0007 and K0009, the wheels must be large enough and positioned so that the user can self-propel the wheelchair;

(A) Adult tilt-in-space wheelchair (E1161):

(i) Ability to tilt the frame of the wheelchair greater than or equal to 20 degrees from horizontal while maintaining the same back-to-seat angle; and

(ii) Lifetime warranty on side frames and crossbraces;

(iii) Wheelchairs with less than 20 degrees of tilt must not be coded based upon the tilt feature. The appropriate base product must be coded as K0001-K0007. Coding as E1161 or K0108 is inappropriate coding.

(B) Standard wheelchair (K0001):

(i) Weight: Greater than 36 pounds;

(ii) Seat height: 19” or greater; and

(iii) Weight capacity: 250 pounds or less.

(i) Weight: Greater than 36 pounds;

(ii) Seat height: Less than 19”; and

(iii) Weight capacity: 250 pounds or less.

(D) Lightweight wheelchair (K0003):

(i) Weight: 34-36 pounds; and

(ii) Weight capacity: 250 pounds or less.

(E) High strength, lightweight wheelchair (K0004):

(i) Weight: Less than 34 pounds; and

(ii) Lifetime warranty on side frames and crossbraces.

(F) Ultra-lightweight wheelchair (K0005):

(i) Weight: Less than 30 pounds;

(ii) Adjustable rear axle position; and

(iii) Lifetime warranty on side frames and crossbraces.

(G) Heavy duty wheelchair (K0006) has a weight capacity greater than 250 pounds;

(H) Extra heavy-duty wheelchair (K0007) has a weight capacity greater than 300 pounds.

(d) Coverage of all adult manual wheelchairs includes the following features:

(A) Seat width: 15"-19";

(B) Seat depth: 15"-19”;

(D) Footrests: Fixed, swing-away, or detachable.

(e) Codes K0003-K0007 and E1161 include any seat height;

(f) For individualized wheelchair features that are medically appropriate to meet the needs of a particular client, use the correct codes for the wheelchair base, options and accessories (see OAR 410-122-0340 Wheelchair Options/Accessories);

(g) For wheelchair frames that are modified in a unique way to accommodate the client, submit the code for the wheelchair base used and submit the modification with code K0108 (wheelchair component or accessory, not otherwise specified);

(h) Manual wheelchair bases (K0001-K0007, K0009) include construction of any type material, including but not limited to, titanium, carbon, or any other lightweight high strength material. Providers shall not bill for construction materials. Billing for construction material is considered incorrect coding and unbundling.

(3) Documentation requirements:

(a) Functional mobility evaluation:

(A) Providers must submit medical documentation that supports conditions of coverage in this rule are met for purchase and modifications of all covered, client-owned manual wheelchairs except for K0001, K0002, or K0003 (unless modifications are required);

(B) Information must include but is not limited to:

(i) The practitioner’s face-to-face examination in accordance with OAR 410-122-0090. The face-to-face examination must occur no more than six (6) months prior to the start of services;

(ii) Medical justification needs assessment, order, and specifications for the wheelchair completed by a physical therapist (PT), occupational therapist (OT), or treating practitioner. The person billing or rendering services who provides this information must have no direct or indirect financial relationship, agreement, or contract with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider requesting authorization;

(iii) Client identification and complex rehab technology supplier identification information that may be completed by the DMEPOS provider; and

(iv) Signature and date by the treating practitioner and the PT or OT.

(C) If the information on this form includes all the elements of an order, the provider may submit the completed form in lieu of an order.

(b) Additional documentation:

(A) Information from a PT, OT, treating practitioner that specifically indicates:

(i) A brief description of the client’s impairment in functional mobility that establishes that they have a mobility limitation and how it interferes with the performance of or participation in activities of daily living;

(ii) Why an appropriately fitted cane or walker cannot sufficiently resolve the client’s mobility limitation.

(B) Pertinent information from a PT, OT, or treating practitioner about the following elements that support coverage criteria are met for a manual wheelchair; only relevant elements need to be addressed:

(i) Symptoms;

(ii) Related diagnoses;

(iii) History:

(I) How long the condition has been present;

(II) Clinical progression;

(III) Interventions that have been tried and the results;

(IV) Past use of walker, manual wheelchair, power-operated vehicle (POV), or power wheelchair and the results.

(iv) Physical exam:

(I) Weight;

(II) Impairment of strength, range of motion, sensation, or coordination of arms and legs;

(III) Presence of abnormal tone or deformity of arms, legs, or trunk;

(IV) Neck, trunk, and pelvic posture and flexibility;

(V) Sitting and standing balance.

(v) Functional assessment indicating any problems with performing the following activities including the need to use a cane, walker, or the assistance of another individual:

(I) Transferring between a bed, chair, and a manual wheelchair or power mobility device;

(II) Walking around their home or community including information on distance walked, speed, and balance.

(C) Documentation from a PT, OT, or treating practitioner that clearly distinguishes the client’s abilities and needs within the home and community;

(D) For all requested equipment and accessories, the manufacturer’s name, product name, model number, standard features, specifications, dimensions, and options;

(E) Detailed information about client-owned equipment (including serial numbers), as well as any other equipment being used or available to meet the client’s medical needs, including how long it has been used by the client and why it cannot be grown (expanded) or modified, if applicable;

(F) If the client shall be using the wheelchair in the home, the DMEPOS provider or practitioner must perform an on-site, written evaluation of the client’s living quarters prior to delivery of the wheelchair. This assessment must support that the client’s home can accommodate and allow for the effective use of a wheelchair. This assessment must include but is not limited to evaluation of physical layout, doorway widths, doorway thresholds, surfaces, counter/table height, accessibility (e.g., ramps), electrical service, etc.; and

(G) All HCPCS codes, including the base, options and accessories, whether prior authorization (PA) is required or not, that shall be billed separately.

(c) A written order by the treating practitioner identifying the specific type of manual wheelchair needed. If the order does not specify the type requested by the DMEPOS provider on the authorization request, the provider must obtain another written order that lists the specific manual wheelchair that is being ordered and any options and accessories requested. The DMEPOS provider may enter the items on this order. This order must be signed and dated by the treating practitioner received by the DMEPOS provider, and submitted to the authorizing authority with a copy of the face-to-face examination required by OAR 410-122-0090;

(d) For purchase of K0001, K0002 or K0003 (without modifications), send documentation listed in (3) (b)(A-E);

(e) When code K0009 is requested, send all information from a PT, OT, or treating practitioner that justifies the medical appropriateness for the item. The only products which may be billed using HCPCS K0009 are those published on the Pricing, Data Analysis, and Coding (PDAC) contractor’s Product Classification List (PCL);

(f) Any additional documentation that supports indications of coverage are met as specified in this policy;

(g) For a manual wheelchair rental, submit all of the following:

(A) A written order from the treating practitioner identifying the specific type of manual wheelchair needed:

(i) If the order does not specify the type of wheelchair requested by the DMEPOS provider on the authorization request, the provider must obtain another written order that lists the specific manual wheelchair that is being ordered and any options and accessories requested;

(ii) The DMEPOS provider may enter the items on this order;

(iii) This order must be signed and dated by the treating practitioner, received by the DMEPOS provider and submitted to the authorizing authority.

(B) HCPCS codes;

(C) Documentation from the DMEPOS provider that supports the client’s home can accommodate and allow for the effective use of the requested wheelchair.

(i) All documentation listed in section (3) of this rule must be kept on file by the DMEPOS provider;

(j) Documentation that coverage criteria have been met must be present in the client’s medical records, and this documentation must be made available to the Division upon request.

(4) Table 122-0320 – Manual Wheelchair Base.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 8-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30- 94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 18-1994(Temp), f. & cert. ef. 4-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0325 Power Wheelchair Base

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover a power wheelchair (PWC) when conditions of coverage in OAR 410-122-0080 and all the following criteria are met:

(A) The client has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in or out of the home. MRADLs include but are not limited to tasks such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation is one that:

(i) Prevents the client from accomplishing an MRADL entirely; or

(ii) Places the client at reasonably determined heightened risk of morbidity or mortality secondary to attempts to perform an MRADL; or

(iii) Prevents the client from completing an MRADL within a reasonable time frame.

(B) An appropriately fitted cane or walker cannot sufficiently resolve the client’s mobility limitation;

(C) The client does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform MRADLs during a typical day:

(i) Assessment of upper extremity function shall consider limitations of strength, endurance, range of motion or coordination, presence of pain, and deformity or absence of one or both upper extremities;

(ii) An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories.

(D) If the client shall be using the PWC in the home, the home provides adequate maneuvering space, maneuvering surfaces, and access between rooms for the operation of the PWC that is being requested;

(E) Use of a PWC shall significantly improve the client’s ability to participate in MRADLs. For clients with severe cognitive and physical impairments, participation in MRADLs may require the assistance of a caregiver;

(F) The presence of a caregiver does not preclude coverage of a PWC if the client is willing and able to safely operate the PWC;

(G) The client is willing to use the requested PWC on a regular basis;

(H) There is objective evidence that demonstrates that the client cannot use a power-operated vehicle (POV);

(I) The client has sufficient mental and physical capabilities to safely operate the PWC;

(J) If the client is unable to safely operate the PWC and has a caregiver, the Division may cover the PWC if the caregiver is unable to adequately propel an optimally-configured manual wheelchair and is available, willing, and able to safely operate the PWC being requested. The caregiver’s need to use a PWC to assist the client with their MRADLs shall be considered in determining coverage;

(K) The client’s weight is less than or equal to the weight capacity of the PWC requested.

(b) Only when conditions of coverage as specified in section (1) (a) of this rule are met may the Division authorize a PWC for any of the following situations:

(A) When the PWC can be reasonably expected to improve the client’s ability to complete MRADLs by compensating for other limitations in addition to mobility deficits, and the client is compliant with treatment:

(i) Besides MRADLs deficits, when other limitations exist, and these limitations can be ameliorated or compensated sufficiently such that the additional provision of a PWC will be reasonably expected to significantly improve the client’s ability to perform or obtain assistance to participate in MRADLs, a PWC may be considered for coverage;

(ii) If the amelioration or compensation requires the client's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial of PWC coverage if it results in the client continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of a PWC.

(B) When a client’s current wheelchair is no longer medically appropriate, or repair and modifications to the wheelchair exceed replacement costs;

(C) When a covered client-owned wheelchair is in need of repair, the Division may pay for one month’s rental of a wheelchair.

(c) For a PWC to be covered, the treating practitioner must conduct a face-to-face examination of the client within six (6) months prior to writing the order and that visit with the treating practitioner starts the six (6) month timeline;

(A) The treating practitioner’s face-to-face examination of the client can be performed during a hospital or nursing facility stay; however, the visit must be conducted within six (6) months prior to writing the order;

(B) The practitioner may refer the client to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), to provide the assessment for the wheelchair. This individual must not be an employee of the DMEPOS provider or have any direct or indirect financial relationship, agreement, or contract with the DMEPOS provider. When the DMEPOS provider is owned by a hospital, a PT/OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination:

(i) If the client was referred to the PT/OT before being seen by the practitioner, then once the practitioner has received and reviewed the written report of this examination, the practitioner must see the client and perform any additional examination that is needed. The practitioner’s report of the visit shall state concurrence or any disagreement with the PT/OT examination and must occur within the six (6) month timeframe;

(ii) If the practitioner examined the client before referring the client to a PT/OT, then again in person after receiving the report of the PT/OT examination, it is also acceptable for the practitioner to review the written report of the PT/OT examination, to sign and date that report, and to state concurrence or any disagreement with that examination. In this situation, the practitioner must send a copy of the note from his initial visit to evaluate the client plus the annotated, signed, and dated copy of the PT/OT examination to the DMEPOS provider;

(iii) If the PWC is a replacement of a similar item that was previously covered by the Division or when only PWC accessories are being ordered and all other coverage criteria in this rule are met, a face-to-face examination is not required.

(d) The Division does not reimburse for another chair if a client has a medically appropriate wheelchair, regardless of payer;

(e) If the client will be using the PWC in the home, the home must be able to accommodate and allow for the effective use of the requested PWC. The Division does not reimburse for adapting the living quarters;

(f) The equipment must be supplied by a DMEPOS provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client;

(g) The ATP must be employed by the provider in a full-time, part-time, or contracted capacity as is acceptable by state law. The ATP, if part-time or contracted, must be under the direct control of the provider;

(h) Documentation must be complete and detailed enough so a third party shall be able to understand the nature of the provider’s ATP involvement, if any, in the licensed/certified medical professional (LCMP) specialty evaluation;

(i) The ATP may not conduct the provider evaluation at the time of delivery of the power mobility device to the client’s residence;

(j) Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair and all covered additions or modifications. Reimbursement also includes support services such as delivery, set-up, pick-up and delivery for repairs/modifications, education, ongoing assistance with use of the wheelchair, and if provided, also includes support services such as emergency services;

(k) The delivery of the PWC must be within 120 days following approval of the PA request by the Division;

(l) A PWC may not be ordered by a podiatrist;

(2) The Division does not consider the following services medically necessary or medically appropriate:

(a) A PWC for clients who are able to independently self-propel an optimally configured manual wheelchair;

(b) A PWC with a captain’s chair for a client who needs a separate wheelchair seat and/or back cushion;

(c) Items or upgrades that primarily allow performance of leisure or recreational activities including but not limited to backup wheelchairs, backpacks, accessory bags, awnings, additional positioning equipment if wheelchair meets the same need, custom colors, and wheelchair gloves;

(3) Coding Guidelines:

(a) Specific types of PWCs:

(A) A Group 1 PWC (K0813-K0816) or a Group 2 PWC (K0820-K0829) may be covered when all of the coverage criteria for a PWC are met and the wheelchair is appropriate for the client’s weight and physical dimensions;

(B) A Group 2 PWC with a seat elevation system (K0830-K0831) may be covered when all of the coverage criteria for a PWC are met, and criteria for a power seat elevation system are met in accordance with OAR 410-122-0340;

(i) When billing a heavy duty or very heavy-duty power wheelchair described by HCPCS codes K0824, K0825, K0826, K0827, K0828, and K0829 that could include a seat elevation system, that system, if included, shall be billed separately under HCPCS code K0108 by using HCPCS codes K0824 - K0829 plus K0108;

(ii) K0108 may also be applied to Group 2 noncomplex heavy-duty bases (K0824, K0825, K0826, K0827, K0828, and K0829) and Group 5 power driven wheelchair bases. For example, a K0825 wheelchair with an accessory seat elevation system shall be billed using K0108.

(C) A Group 2 Single Power Option PWC (K0835 – K0840) may be covered when the coverage criteria for a PWC are met; and if

(i) One of the following criteria I or II is met, and the following criteria in (ii) are met:

(I) The client requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control); or

(II) The client meets the coverage criteria for a power tilt or recline seating system and the system is being used on the wheelchair;

(ii) All of the following criteria I and II are met:

(I) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, nurse practitioner, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical appropriateness for the wheelchair and its special features (see Documentation Requirements in section (3) of this rule). The PT, OT, nurse practitioner, or practitioner billing or rendering services must have no financial relationship with the DMEPOS provider; and

(II) The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client.

(D) A Group 2 Multiple Power Option PWC (K0841, K0842, K0843) may be covered when the coverage criteria for a PWC are met, and if:

(i) One of the following criteria I or II is met, and the following criteria in (ii) are met:

(I) The client meets the coverage criteria for a power tilt or recline seating system and the system is being used on the wheelchair; or

(II) The client uses a ventilator that is mounted on the wheelchair;

(ii) All of the following criteria I and II are met:

(I) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical appropriateness for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner billing or rendering services must have no financial relationship with the DMEPOS provider; and

(E) A Group 3 PWC with no power options (K0848-K0855) may be covered when:

(i) The coverage criteria for a PWC are met; and

(ii) The client’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and

(iii) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner billing or rendering services must have no financial relationship with the DMEPOS provider; and

(iv) The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client;

(F) A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power Options (K0861-K0864) may be covered when:

(i) The Group 3 criteria in section (2)(a)(D) (i-ii) are met; and

(ii) The Group 2 Single Power Option in section (2)(a)(B) or Multiple Power Options section (2)(a)(C) (respectively) are met.

(G) Requests for Group 4 PWCs shall be reviewed on a case-by-case basis. Client specific clinical documentation must be submitted that supports the medical need for this level of PWC and demonstrates that there is no equally effective, less costly PWC that meets the client’s medical needs.

(H) Requests for power wheelchairs not otherwise classified (K0898) shall be reviewed on a case-by-case basis. Client specific clinical documentation must be submitted that supports the individual’s medical need and demonstrates that there is no equally effective, less costly PWC that meets the client’s medical needs.

(I) A power assist system (E0986) for a manual wheelchair may be covered if all of the following criteria are met:

(i) The client meets criteria for a power wheelchair but does not require a fully-powered wheelchair; and

(ii) The client has demonstrated ability to self-propel in a manual wheelchair or a history of self-propelling for at least one year; and

(iii) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as physical therapist (PT) or occupational therapist (OT), or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical need for the device; and

(v) E0986 is all-inclusive. All components, e.g., drive wheels, batteries, chargers, controls, mounting hardware, etc, for a manual wheelchair conversion are included in this code.

(b) PWC Basic Equipment Package: Each PWC code is required to include the following items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted):

(A) Lap belt or safety belt;

(B) Battery charger, single mode;

(D) Legrests: There is no separate billing or payment if fixed, swing away, or detachable non-elevating leg rests with or without calf pad are provided. Elevating legrests may be billed separately;

(E) Footrests/foot platform: There is no separate billing or payment if fixed, swingaway or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 power wheelchairs. Angle adjustable footplates may be billed separately with Group 3, 4 or 5 power wheelchairs;

(F) K0040 may be billed separately with K0848 through K0864;

(G) Armrests: There is no separate billing or payment if fixed, swingaway, or detachable non-adjustable armrests with arm pad are provided. Adjustable height armrests may be billed separately;

(H) Upholstery for seat and back of proper strength and type for patient weight capacity of the power wheelchair;

(I) Weight specific components (braces, bars, upholstery, brackets, motors, gears) as required by patient weight capacity;

(J) Controller and Input Device: There is no separate billing or payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a non-standard joystick (i.e., non-proportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

(c) If a client needs a seat and/or back cushion but does not meet coverage criteria for a skin protection and/or positioning cushion, it may be appropriate to request a captain’s chair seat rather than a sling/solid seat/back and a separate general use seat and/or back cushion;

(d) A PWC with a seat width or depth of 14” or less is considered a pediatric PWC base and is coded E1239, PWC, pediatric size, not otherwise specified (see OAR 410-122-0720 Pediatric Wheelchairs);

(4) Prior Authorization (PA): All codes in this rule require PA and may be purchased, rented, and repaired. Submit all of the following documentation with the PA request:

(a) A copy of the written report of the face-to-face examination of the client by the practitioner:

(A) This report must include information related to the following:

(i) This client’s mobility limitation and how it interferes with the performance of activities of daily living;

(ii) Why a cane or walker cannot sufficiently resolve the client’s mobility limitation;

(iii) Why a manual wheelchair cannot sufficiently resolve the client’s mobility limitation;

(iv) Why a POV/scooter cannot sufficiently resolve the client’s mobility limitation;

(v) The client’s physical and mental abilities to operate a PWC safely:

(I) Besides a mobility limitation, if other conditions exist that limit a client’s ability to participate in activities of daily living (ADLs), how these conditions shall be ameliorated or compensated by use of the wheelchair;

(II) How these other conditions shall be ameliorated or compensated sufficiently such that the provision of a PWC shall be reasonably expected to significantly improve the client’s ability to perform or obtain assistance to participate in MRADLs.

(B) The face-to-face examination shall provide pertinent information about the following elements. Only relevant elements need to be addressed:

(i) Symptoms;

(ii) Related diagnoses;

(iii) History:

(I) How long the condition has been present;

(II) Clinical progression;

(III) Interventions that have been tried and the results;

(IV) Past use of walker, manual wheelchair, POV, or PWC and the results.

(iv) Physical exam:

(I) Weight;

(II) Impairment of strength, range of motion, sensation, or coordination of arms and legs;

(III) Presence of abnormal tone or deformity of arms, legs, or trunk;

(IV) Neck, trunk, and pelvic posture and flexibility;

(V) Sitting and standing balance.

(v) Functional assessment indicating any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person:

(I) Transferring between a bed, chair, and power mobility device;

(II) Walking around their home or community including information on distance walked, speed, and balance.

(b) The practitioner’s written order received by the DMEPOS provider within 45 days (date stamp or equivalent must be used to document receipt date) after the practitioner’s face-to-face examination. The order must include all of the following elements:

(A) Client’s name;

(B) Description of the item that is ordered. This may be general (e.g., “power wheelchair” or “power mobility device”) or may be more specific:

(i) If this order does not identify the specific type of PWC that is being requested, the DMEPOS provider must clarify this by obtaining another written order that lists the specific PWC that is being ordered and any options and accessories requested;

(ii) The items on this clarifying order may be entered by the DMEPOS provider. This subsequent order must be signed and dated by the treating practitioner, received by the DMEPOS provider, and submitted to the authorizing authority, but does not have to be received within 45 days following the face-to-face examination.

(D) Pertinent diagnoses/conditions and diagnosis codes that relate specifically to the need for the PWC;

(E) Length of need;

(F) Practitioner’s signature;

(G) Date of practitioner’s signature.

(c) For all requested equipment and accessories, the manufacturer’s name, product name, model number, standard features, specifications, dimensions, and options;

(d) Detailed information about client-owned equipment (including serial numbers) as well as any other equipment being used or available to meet the client’s medical needs, including how long it has been used by the client and why it cannot be grown (expanded) or modified, if applicable;

(e) If the client shall be using the PWC in the home, the DMEPOS provider or practitioner must perform an on-site, written evaluation of the client’s living quarters, prior to delivery of the PWC. This assessment must support that the client’s home can accommodate and allow for the effective use of a PWC. Assessment must include but is not limited to evaluation of physical layout, doorway widths, doorway thresholds, surfaces, counter or table height, accessibility (e.g., ramps), electrical service, etc.;

(f) A written document (termed a detailed product description) prepared by the DMEPOS provider and signed and dated by the practitioner that includes:

(i) The specific base (HCPCS code and manufacturer name/model) and all options and accessories (including HCPCS codes), whether PA is required or not, that shall be billed separately;

(ii) The DMEPOS provider’s charge and the Division fee schedule allowance for each separately billed item;

(iii) If there is no Division fee schedule allowance, the DMEPOS provider must enter “not applicable”;

(iv)The DMEPOS provider must receive the signed and dated detailed product description from the practitioner prior to delivery of the PWC;

(v) A date stamp or equivalent must be used to document receipt date of the detailed product description.

(g) Any additional documentation that supports indications of coverage are met as specified in this rule;

(h) The DMEPOS provider must keep the above documentation on file;

(i) Documentation that the coverage criteria have been met must be present in the client’s medical records and made available to the Division upon request.

(5) Reimbursement:

(a) Codes specified in this rule shall not be reimbursed for clients residing in nursing facilities;

(b) Reimbursement on standard Group 1 and Group 2 wheelchairs without power option (K0813-K0816, K0820-K0829) shall only be made on a monthly rental basis;

(c) Rented equipment is considered purchased after thirteen (13) continuous months of rent or the Division fee schedule purchase price or the actual charge from the provider is met, whichever is less.

(6) Documentation:

(a) For services requiring prior authorization, submit documentation that supports coverage criteria in this rule are met;

(b) Documentation that the coverage criteria have been met must be present in the client’s medical record. This documentation and any additional medical information from the DMEPOS provider must be made available to the Division upon request.

(7) Procedure codes:

(a) The Medicare Pricing, Data Analysis and Coding (PDAC) contractor assists DMEPOS providers and manufacturers in determining which codes shall be used to describe DMEPOS items. See 410-122-0180 Healthcare Common Procedure Coding System (HCPCS) Level II Coding for more information;

(b) Refer to the product classification list on the PDAC contractor website for appropriate HCPCS codes.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 9-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 57-2012, f. & cert. ef 12-27-12
DMAP 31-2012(Temp), f. 6-29-12, cert. ef. 7-1-12 thru 12-27-12
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0330 Power-Operated Vehicle

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover a power-operated vehicle (POV) when conditions of coverage in OAR 410-122-0080 and all of the following criteria are met:

(A) The client has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in or out of the home. MRADLs include but are not limited to tasks such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation is one that:

(i) Prevents the client from accomplishing an MRADL entirely; or

(ii) Places the client at reasonably determined heightened risk of morbidity or mortality secondary to attempts to perform an MRADL; or

(iii) Prevents the client from completing an MRADL within a reasonable time frame.

(B) An appropriately fitted cane or walker cannot resolve the client’s mobility limitation;

(C) The client does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform MRADLs during a typical day:

(i) Assessment of upper extremity function shall consider limitations of strength, endurance, range of motion, or coordination, presence of pain, and deformity or absence of one or both upper extremities;

(ii) An optimally-configured manual wheelchair features an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories.

(D) The client has sufficient strength, postural stability, or other physical or mental capabilities needed to safely operate a POV;

(E) If the client shall be using the POV in the home, the client’s home provides adequate maneuvering space, maneuvering surfaces, and access between rooms for the operation of the POV being requested. The Division does not reimburse for adapting living quarters;

(F) The client is able to:

(i) Safely transfer to and from the POV;

(ii) Operate the tiller steering system, and

(iii) Maintain postural stability and position while operating the POV.

(G) Use of a POV shall significantly improve the client’s ability to participate in their MRADLs;

(H) The client is willing to use the requested POV on a regular basis;

(I) The Division does not cover services or upgrades that primarily allow performance of leisure or recreational activities. Such services include but are not limited to backup POVs, backpacks, accessory bags, awnings, additional positioning equipment if the POV meets the same need, custom colors, and wheelchair gloves.

(b) For a POV to be covered, the treating practitioner or nurse practitioner must conduct a face-to-face examination of the client within six (6) months before writing the order, and that visit with the treating practitioner starts the six (6) month timeline;

(A) The treating practitioner’s face-to-face examination can be performed during a hospital or nursing facility stay; however, the visit must be conducted within six (6) months prior to writing the order;

(B) The practitioner may refer the client to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), to perform part of this face-to-face examination. This person may not be an employee of the DMEPOS provider or have any direct or indirect financial relationship, agreement, or contract with the DMEPOS provider. When the DMEPOS provider is owned by a hospital, a PT/OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination:

(iii) If the POV is a replacement of a similar item that was previously covered by the Division or when only POV accessories are being ordered and all other coverage criteria in this rule are met, a face-to-face examination is not required.

(2) The Division does not consider the following services medically necessary or medically appropriate:

(a) POV for clients who are able to ambulate with the help of assistive equipment or independently able to self-propel an optimally-configured manual wheelchair;

(b) A POV used to replace private or public transportation such as an automobile, bus, or taxi;

(c) If a POV is covered, a manual or power wheelchair provided at the same time or subsequently shall be considered for denial as not medically appropriate;

(3) Coding guidelines:

(a) Group 1 POVs (K0800 — K0802) are typically used only inside the home;

(b) Group 2 POVs (K0806 –K0808) have added capabilities not needed for in home use. Client specific clinical documentation must be submitted that supports the medical need for this level of POV and demonstrates that there is no equally effective, less costly alternative that meets the client’s medical needs;

(c) A replacement item including but not limited to replacement batteries shall be requested using the specific wheelchair option or accessory code if one exists (see 410-122-0340, Wheelchairs Options/Accessories). If a specific code does not exist, use code K0108 (wheelchair component or accessory, not otherwise specified);

(d) For guidance on correct coding, DMEPOS providers shall contact the Pricing, Data Analysis and Coding (PDAC) Contractor by the Centers for Medicare and Medicaid Services. See 410-122-0180 Healthcare Common Procedure Coding System (HCPCS) Level II Coding for more information.

(4) Prior Authorization (PA): Submit all of the following documentation with the PA request:

(a) A copy of the written report of the face-to-face examination of the client by the practitioner:

(A) The report must include information related to the following:

(i) The client’s mobility limitation and how it interferes with the performance of activities of daily living;

(ii) Why a cane or walker cannot sufficiently resolve the client’s mobility limitations;

(iii) Why a manual wheelchair cannot sufficiently resolve the client’s mobility limitations;

(iv) The client’s physical and mental abilities to operate a POV (scooter):

(I) Besides a mobility limitation, if other conditions exist that limit a client’s ability to participate in MRADLs, how these conditions shall be ameliorated or compensated;

(II) How these other conditions shall be ameliorated or compensated sufficiently such that the additional provision of   POV shall be reasonably expected to significantly improve the client’s ability to perform or obtain assistance to participate in MRADLs.

(B) The face-to-face examination shall provide pertinent information about the following elements but may include other details. Only relevant elements need to be addressed:

(i) Symptoms;

(ii) Related diagnoses;

(iii) History:

(I) How long the condition has been present;

(II) Clinical progression;

(III) Interventions that have been tried and the results;

(IV) Past use of walker, manual wheelchair, POV, or power wheelchair and the results;

(iv) Physical exam:

(I) Weight;

(II) Impairment of strength, range of motion, sensation, or coordination of arms and legs;

(III) Presence of abnormal tone or deformity of arms, legs, or trunk;

(IV) Neck, trunk, and pelvic posture and flexibility;

(V) Sitting and standing balance.

(v) Functional assessment indicating any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person:

(I) Transferring between a bed, chair, and power mobility device;

(II) Walking around their home or community including information on distance walked, speed, and balance.

(b) The practitioner’s written order, received by the DMEPOS provider within thirty (30) days after the practitioner’s face-to-face examination that includes all of the following elements:

(A) Client’s name;

(B) Description of the item that is ordered. This may be general (e.g., “POV” or “power mobility device”) or may be more specific:

(i) If this order does not identify the specific type of POV that is being requested, the DMEPOS provider must clarify this by obtaining another written order that lists the specific POV that is being ordered and any options and accessories requested;

(ii) The items on this order may be entered by the DMEPOS provider. This subsequent order must be signed and dated by the treating practitioner, received by the DMEPOS provider, and submitted to the authorizing authority, but does not have to be received within 45 days following the face-to-face examination.

(D) Length of need;

(E) Practitioner’s signature;

(F) Date of practitioner’s signature.

(c) For all requested equipment and accessories, include the manufacturer’s name, product name, model number, standard features, specifications, dimensions, and options;

(d) Detailed information about client-owned equipment (including serial numbers) as well as any other equipment being used or available to meet the client’s medical needs, including the age of the equipment and why it cannot be grown (expanded) or modified, if applicable;

(e) A written evaluation of the client’s living quarters performed by the DMEPOS provider. This assessment must support that the client’s home can accommodate and allow for the effective use of a POV, including but is not limited to evaluation of door widths, counter/table height, accessibility (e.g., ramps), electrical service, etc.;

(f) All HCPCS to be billed on this claim (both codes that require authorization and those that do not require authorization);

(g) Any additional documentation that supports indications of coverage are met as specified in this rule;

(h) The above documentation must be kept on file by the DMEPOS provider;

(5) Reimbursement:

(a) Codes specified in this rule shall not be reimbursed for clients residing in nursing facilities;

(b) If a client has a medically appropriate POV regardless of payer, the Division shall not reimburse for another POV;

(c) The cost of the POV includes all options and accessories that are provided at the time of initial purchase, including but not limited to batteries, battery chargers, weight appropriate upholstery and seating system, tiller steering, non-expandable controller with proportional response to input, complete set of tires, and all accessories needed for safe operation;

(d) Reimbursement for the POV includes all labor charges involved in the assembly of the POV and all covered additions or modifications. Reimbursement also includes support services such as emergency services, delivery, set-up, pick-up and delivery for repairs/modifications, education, and on-going assistance with use of the POV;

(e) If a client-owned POV meets coverage criteria, medically appropriate replacement items including but not limited to batteries may be covered;

(f) The Division may cover a new POV when a client’s existing POV is no longer medically appropriate or repair and modifications to the POV exceed replacement costs;

(g) The Division shall cover one month’s rental of a POV if a client-owned POV is being repaired;

(h) The Division shall purchase, rent, and repair;

(A) Rental charges apply toward purchase;

(B) Item is considered purchased when the Division fee schedule purchase price or the actual charge from the provider is met, whichever is less.

(6) Documentation:

(a) For services requiring prior authorization, submit documentation that supports coverage criteria in this rule are met;

(7) Procedure Codes:

(a) K0800 Power operated vehicle, Group 1 standard, patient weight capacity up to and including 300 pounds — PA;

(b) K0801 Power operated vehicle, Group 1 heavy duty, patient weight capacity, 301 to 450 pounds — PA;

(d) K0806 Power operated vehicle, Group 2 standard, patient weight capacity up to and including 300 pounds — PA

(e) K0807 Power operated vehicle, Group 2 heavy-duty, patient weight capacity 301 to 450 pounds — PA

(f) K0808 Power operated vehicle, Group 2 very heavy-duty, patient weight capacity 451 to 600 pounds — PA

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0340 Wheelchair Options/Accessories

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover options and accessories for covered wheelchairs when the following criteria are met:

(A) The client has a wheelchair that meets Division coverage criteria; and

(B) The client requires the options/accessories to participate in one or more mobility-related activities of daily living (MRADLs) in the home, community or any non-institutional setting in which normal life activities take place. See OAR 410-122-0010, Definitions for definition of MRADLs.

(b) The Division does not consider options/accessories whose primary benefit is allowing the client to perform leisure or recreational activities medically necessary and/or medically appropriate;

(A) Adjustable arm height option (E0973, K0017, K0018, and K0020) may be covered when the client:

(i) Requires an arm height that is different than what is available using nonadjustable arms; and

(ii) Spends at least two (2) hours per day in the wheelchair.

(B) An arm trough (E2209) is covered if the client has quadriplegia, hemiplegia, or uncontrolled arm movements.

(d) Footrest/Legrest:

(A) Elevating legrests (E0990, K0046, K0047, K0053, and K0195) may be covered when:

(i) The client has a musculoskeletal condition or the presence of a cast or brace that prevents 90-degree flexion at the knee;

(ii) The client has edema of the lower extremities that requires having an elevating legrest; or

(iii) The client meets the criteria for and has a reclining back on the wheelchair.

(B) Elevating legrests that are used with a wheelchair that is purchased or owned by the patient are coded E0990. This code is per legrest;

(C) Elevating legrests that are used with a capped rental wheelchair base shall be coded K0195. This code is per pair of legrests.

(D) A footbox (E0954) is a padded box designed to position a client’s foot. This item comes in multiple configurations and may be for a single foot or for both feet. Regardless of configuration, the unit of service is per foot.  E0954 includes both prefabricated and custom fabricated products. The code also includes all mounting hardware so E1028 is not separately payable with this code.

(e) Nonstandard Seat Frame Dimensions:

(A) For all adult wheelchairs, payment for seat widths or seat depths of 15-19 inches is included in the payment for the base code. These seat dimensions shall not be billed separately;

(B) Codes E2201-E2204 and E2340-E2343 describe seat widths or depths of 20 inches or more for manual or power wheelchairs;

(C) A nonstandard seat width or depth (E2201-E2204 and E2340-E2343) is covered only if the patient's dimensions justify the need.

(f) Rear Wheels for Manual Wheelchairs. Code E2213 (flat free insert) is used to describe either:

(A) A removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured; or

(B) Non-removable foam material in a foam filled rubber tire;

(g) Batteries/Chargers:

(A) Up to two batteries (E2359-E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair;

(B) Batteries/chargers (E2366) for power wheelchairs are payable separately from the purchased wheelchair base.

(h) Seating:

(A) The Division may cover a general use seat cushion and a general-use wheelchair back-cushion for a client whose wheelchair meets Division coverage criteria;

(B) A skin protection seat cushion may be covered for a client who meets both of the following criteria:

(i) The client has a wheelchair that meets Division coverage criteria; and

(ii) The client has either of the following:

(I) Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or

(II) Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift.

(C) A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0953, E0955-E0957, E0960) may be covered for a client who meets both of the following criteria:

(i) The client has a wheelchair with a sling/solid seat/back and client meets Division coverage criteria; and

(ii) The client has any significant postural asymmetries.

(D) A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) may be covered when a client meets the criteria for both a skin protection seat cushion and a positioning seat cushion;

(E) Separate payment is allowed for a seat cushion solid support base (E2231) with mounting hardware when it is used on an adult manual wheelchair (K0001-K0009, E1161).  Separate payment is not allowed for the solid support base and mounting hardware when it is used on a power wheelchair;

(F) There is no separate payment for a solid insert (E0992) that is used with a seat or back cushion because a solid base is included in the allowance for a wheelchair seat or back cushion;

(G) There is no separate payment for mounting hardware for a seat or back cushion;

(H) There is no separate payment for a headrest (E0955, E0966) on a captain’s seat on a power wheelchair;

(I) A custom fabricated seat cushion (E2609) and a custom fabricated back cushion (E2617) are cushions that are individually made for a specific patient:

(i) Basic materials include liquid foam or a block of foam and sheets of fabric or liquid coating material:

(I) A custom fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts). These components may not be billed separately;

(II) The cushion must have a removable vapor permeable or waterproof cover, or it must have a waterproof surface.

(ii) The cushion must be fabricated using molded-to-patient-model technique, direct molded-to-patient technique, computer-aided design and computer-aided manufacturing (CAD-CAM) technology, or detailed measurements of the patient used to create a configured cushion:

(I) If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual client, the cushion must be billed as a prefabricated cushion, not custom fabricated;

(II) The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion.

(iii) If a custom fabricated seat and back are integrated into a one-piece cushion, code as E2609 plus E2617.

(J) A custom fabricated seat cushion may be covered if criteria in subparagraph (i) and (iii) are met. A custom fabricated back cushion may be covered if criteria subparagraph (ii) and (iii) are met:

(i) Client meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;

(ii) Client meets all of the criteria for a prefabricated positioning back cushion;

(iii) There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), who is not an employee of or otherwise paid by a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider, which clearly explains why a prefabricated seating system is not sufficient to meet the client's seating and positioning needs.

(K) A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion that has not received coding verification as published by the Pricing, Data Analysis and Coding (PDAC) contractor by the Centers for Medicare and Medicaid Services; or that does not meet the criteria stated in this rule is not covered;

(L) A headrest extension (E0966) is a sling support for the head. Code E0955 describes any type of cushioned headrest;

(M) The code for a seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, that is an integral part of the cushion;

(N) A solid insert (E0992) is a separate rigid piece of wood or plastic that is inserted in the cover of a cushion to provide additional support and is included in the allowance for a seat cushion;

(O) A solid support base for a seat cushion is a rigid piece of plastic or other material that is attached with hardware to the seat frame of a wheelchair in place of a sling seat. A cushion is placed on top of the support base. Use code E2231 for this solid support base that is used with a manual wheelchair. A solid support base is included in the allowance for power wheelchair codes. Separate payment is not allowed for a solid support base and mounting hardware when it is used on a power wheelchair;

(i) The Division shall only cover accessories billed under the following codes when PDAC lists the use of the code for the specific product being billed: E2601-E2608, E2610-E2616, E2620-E2625, E2609 and E2617 (brand-name products); K0108 (for wheelchair cushions):

(A) PDAC coding is available and can be verified on the PDAC website or by contacting PDAC;

(B) A product classification list with products that have received a coding verification can be found on the PDAC website.

(j) Code E1028 shall be used to bill manual swingaway, retractable, or removable mounting hardware for wheelchair accessories that include mounting hardware such as (not all-inclusive): swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and swingaway hardware for an indicator display box that is related to the multi-motor electronic connection E2310 or E2311. E1028 may be billed in addition to codes E0953 andE0957. E1028 shall not be billed in addition to codes E0950, E0954, E0960, or E1020 as mounting hardware is included in the allowance for these codes. E1028 shall not be used for mounting hardware related to a wheelchair seat cushion or back cushion code. Code E1032 shall be used to bill manual swingaway, retractable or removable mounting hardware for wheelchair accessories described by joysticks or other drive control interfaces. E1032 shall not be billed in addition to code E2325 as mounting hardware is included in the allowance for this code. Code E1033 shall be used to bill manual swingaway, retractable or removable mounting hardware for headrest and may be billed with code E0955. E1034 shall be used to bill manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support and may be billed with code E0956. Powered swingaway or retractable mounting hardware shall be billed using HCPCS code K0108;

(k) Power seating systems – tilt only, recline only, or combination tilt and recline, with or without elevating leg rests may be covered when A-D are met and to treat conditions such as, but not limited to E-I:

(A) The client has met criteria for a power wheelchair; and

(B) A specialty evaluation was performed by a licensed/certified physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary’s seating and positioning needs and

(D) The wheelchair is or was provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary;

(E) The client is at risk for developing a pressure ulcer and is unable to change positioning or perform a functional weight shift; or

(F) The client utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed; or

(G) The power seating system is needed to manage increased tone or spasticity; or

(H) For clients with absent or impaired sensation and at risk for developing a pressure injury; or

(I) The power seating system is needed to manage chronic edema;

(i) A power-tilt seating system (E1002) includes all the following:

(I) A solid seat platform and a solid back; any frame width and depth;

(II) Detachable or flip-up fixed height or adjustable height armrests;

(III) Fixed or swingaway detachable legrests;

(IV) Fixed or flip-up footplates;

(V) Motor and related electronics with or without variable speed programmability;

(VI) Switch control that is independent of the power wheelchair drive control interface;

(VII) Any hardware that is needed to attach the seating system to the wheelchair base.

(ii) It does not include a headrest;

(iii) It must have the following features:

(I) Ability to tilt to greater than or equal to 20 degrees from horizontal;

(II) Ability for the supplier to adjust the seat to back angle;

(III) Ability to support patient weight of at least 250 pounds.

(iv) A power recline seating system (E1003-E1005) includes the following:

(I) A solid seat platform and a solid back;

(II) Any frame width and depth;

(III) Detachable or flip-up fixed height or adjustable height arm rests;

(IV) Fixed or swingaway detachable legrests;

(V) Fixed or flip-up footplates;

(VI) A motor and related electronics with or without variable speed programmability;

(VII) A switch control that is independent of the power wheelchair drive control interface;

(VIII) Any hardware that is needed to attach the seating system to the wheelchair base.

(v) It does not include a headrest;

(vi) It must have the following features:

(I) Ability to recline to greater than or equal to 150 degrees from horizontal;

(II) Back height of at least 20 inches;

(III) Ability to support patient weight of at least 250 pounds.

(vii) A power tilt and recline seating system (E1006-E1008) includes the following:

(I) A solid seat platform and a solid back;

(II) Any frame width and depth; detachable or flip-up fixed height or adjustable height armrests;

(III) Fixed or swing-away detachable legrests; fixed or flip-up footplates;

(IV) Two motors and related electronics with or without variable speed programmability;

(V) Switch control that is independent of the power wheelchair drive control interface;

(VI) Any hardware that is needed to attach the seating system to the wheelchair base.

(viii) It does not include a headrest;

(ix) It must have the following features:

(I) Ability to tilt to greater than or equal to 20 degrees from horizontal;

(II) Ability to recline to greater than or equal to 150 degrees from horizontal;

(III) Back height of at least 20 inches; ability to support patient weight of at least 250 pounds.

(J) Coding for a power tilt system (E1002), power recline system (E1003-E1005), and tilt/recline system (E1006-E1008) are all inclusive. Billing K0108 for additional heavy duty or bariatric features is considered unbundling and not allowed;

(K) A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the posterior back panel reclines or raises, a mechanical linkage between the two panels allows the client's back to stay in contact with the anterior panel without sliding along that panel;

(L) A power shear reduction feature (E1005 and E1008) consists of two separate back panels. As the posterior back panel reclines or raises, a separate motor controls the linkage between the two panels and allows the client's back to stay in contact with the anterior panel without sliding along that panel;

(M) A power leg elevation feature (E1010, E1012) involves a dedicated motor and related electronics with or without variable speed programmability that allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control that may or may not be integrated with the power tilt and recline controls;

(N) A center mount power elevating leg rest/platform includes all components of the leg rest, including fixed angle footplates and foot platforms. Adjustable angle footplates coded K0040 are separately payable when provided with leg rests coded as E1012.

(l) Codes E2298, E2310 and E2311 (Power Wheelchair Accessory):

(A) Describe the electronic components that allow the client to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): Power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing;

(B) Include a function selection switch that allows the client to select the motor that is being controlled and an indicator feature to visually show which function has been selected;

(C) When the wheelchair drive function is selected the indicator feature may also show the direction that is selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface;

(D) Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present);

(E) When a switch is medically appropriate and a client has adequate hand motor skills, a switch shall be considered the least costly alternative;

(F) E2298, power seat elevation system, may be covered for clients using complex power wheelchairs, when one of the following criteria (i) or (ii) are met and (iii)-(iv) are met:

(i) The client must routinely transfer between uneven surfaces and the seat elevation feature allows them to accomplish transfers independently or with caregiver assistance; or

(ii) The client cannot be safely transferred using a patient lift or standing transfer and can safely transfer with the seat elevation feature; and

(iii) The seat elevation feature has been demonstrated to allow the client to access areas in the home or community necessary to perform their MRADLs; and

(iv) The client has had a specialty evaluation that documents the medical need and client’s ability to safely operate the seat elevation equipment. This evaluation must be performed by a licensed/certified medical professional, such as physical therapist (PT) or occupational therapist (OT), or practitioner who has specific training and experience in rehabilitation wheelchair evaluations.

(G) Power seat elevation systems added to complex rehabilitative power wheelchairs (K0835-K0864) and Group 5 power wheelchairs (K0890, K0891) must use code E2298.

(H) Code E2298 cannot be added to any non-complex power wheelchair base (K0813-K0829). HCPCS codes K0830 and K0831 for Group 2 standard base wheelchairs (non-complex) include the seat elevation feature and may be used if client meets criteria for the power wheelchair and the seat elevation criteria are met.

(I) E2310 or E2311 may be covered when a client does not have hand motor skills or presents with cognitive deficits, contractures, or limitation of movement patterns that prevents operation of a switch;

(J) In addition, an alternate switching system must be medically appropriate and not hand controlled (not running through a joystick).

(m) Power Wheelchair Drive Control Systems:

(A) The term interface in the code narrative and definitions describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include but are not limited to joystick, sip and puff, chin control, head control, etc.;

(B) A proportional interface is one in which the direction and amount of movement by the client controls the direction and speed of the wheelchair. One example of a proportional interface is a standard joystick;

(C) A non-proportional interface is one that involves a number of switches. Selecting a particular switch determines the direction of the wheelchair, but the speed is pre-programmed. One example of a non-proportional interface is a sip-and-puff mechanism;

(D) The term controller describes the microprocessor and other related electronics that receive and interpret input from the joystick (or other drive control interface) and convert that input into power output to the motor and gears in the power wheelchair base;

(E) A non-expandable controller has the following features:

(i) May have the ability to control up to two (2) power seating actuators through switches or the drive control (for example, seat elevator and single actuator power elevating leg rests). Control of these items through the Control Input Device would require the use of an additional component, E2310 or E2311); and

(ii) Can accommodate only an integral joystick or a standard proportional remote joystick; and

(iii) May allow for the incorporation of an attendant control;

(F) An expandable controller is capable of accommodating or operating one or more of the following additional functions or devices:

(i) Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc);

(ii) Non-proportional input devices (e.g., sip and puff, head array, etc);

(iii) Operate three (3) or more powered seating actuators through switches or the drive control. Control of these items through the Control Input Device shall require the use of an additional component, E2310 or E2311;

(iv) A separate display;

(v) Other electronic devices (e.g., augmentative communication device)

(vi) An attendant control;

(G) For power wheelchairs capable of being upgraded to an expandable controller, E2377 is used if an expandable controller is provided at the time of initial issue.  Code E2376 is used with complete replacement of an expandable controller;

(H) A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It includes all necessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement.

(I) A switch is an electronic device that turns power to a particular function either “on” or “off.” The external component of a switch may be either mechanical or non-mechanical. Mechanical switches involve physical contact in order to be activated. Examples of the external components of mechanical switches include but are not limited to toggle, button, ribbon, etc. Examples of the external components of non-mechanical switches include but are not limited to proximity, infrared, Bluetooth, fiber optic, etc. Some of the codes include multiple switches. In those situations, each functional switch may have its own external component, or multiple functional switches may be integrated into a single external switch component, or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component;

(J) A stop switch allows for an emergency stop when a wheelchair with a non-proportional interface is operating in the latched mode. (Latched mode is when the wheelchair continues to move without the patient having to continually activate the interface.) This switch is sometimes referred to as a kill switch;

(K) A direction change switch allows the client to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. For example, it allows a switch to initiate forward movement one time and backward movement another time;

(L) A function selection switch allows the client to determine what operation is being controlled by the interface at any particular time. Operations may include but are not limited to drive forward, drive backward, tilt forward, recline backward, etc.;

(M) An integrated proportional joystick and controller is an electronics package in which a joystick and controller electronics are in a single box that is mounted on the arm of the wheelchair;

(N) The interfaces described by codes E2312, E2321, E2322, E2325, and E2327-E2330, E2373-E2377 must have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking;

(O) A mini-proportional (short-throw) remote joystick (E2312) can only be used with an expandable controller. There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick;

(P) A remote joystick (E2321) is one in which the joystick is in one box that is mounted on the arm of the wheelchair and the controller electronics are located in a different box that is typically located under the seat of the wheelchair;

(Q) When code E2321 is used for a chin control interface, the chin cup is billed separately with code E2324;

(R) Code E2322 describes a system of 3-5 mechanical switches that are activated by the client touching the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch, and a mechanical direction change switch, if provided, are included in the allowance for the code;

(S) Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick, e.g., U shape or T shape or that have some other nonstandard feature, e.g., flexible shaft;

(T) A sip and puff interface (E2325) is a non-proportional interface in which the client holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A mechanical stop switch is included in the allowance for the code. E2325 does not include the breath tube kit that is described by code E2326;

(U) A proportional, mechanical head control interface (E2327) is one in which a headrest is attached to a joystick-like device. The direction and amount of movement of the client’s head pressing on the headrest control the direction and speed of the wheelchair. A mechanical direction control switch is included in the code;

(V) A proportional, electronic head control interface (E2328) is one in which a client’s head movements are sensed by a box placed behind the client’s head. The direction and amount of movement of the client’s head (which does not come in contact with the box) control the direction and speed of the wheelchair. A proportional, electronic extremity control interface (E2328) is one in which the direction and amount of movement of the client’s arm or leg control the direction and speed of the wheelchair;

(W) A non-proportional, contact switch head control interface (E2329) is one in which a client activates one of three mechanical switches placed around the back and sides of their head. These switches are activated by pressure of the head against the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included in the allowance for the code;

(X) A non-proportional, proximity switch head control interface (E2330) is one in which a client activates one of three switches placed around the back and sides of their head. These switches are activated by movement of the head toward the switch, though the head does not touch the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included in the allowance for the code;

(Y) Code K0108 may not be used for additional features of a joystick. K0108 is appropriately used at the time of replacement in the following situations:

(i) An integrated proportional joystick and controller box are being replaced due to damage; or

(ii) An interface other than a remote joystick (e.g., sip and puff, head control) is being replaced but the controller is not being replaced; or

(iii) There is no specific E code which describes the type of drive control interface system which is provided;

(Z) The KC modifier (replacement of special power wheelchair interface) shall not be used at the time of initial issue of a wheelchair but may be used in the following situations:

(i) Due to a change in the client’s condition an integrated joystick and controller is being replaced by another drive control interface, e.g., remote joystick, head control, sip and puff, etc.; or

(ii) The client has a drive control interface described by codes E2320-E2322, E2325, or E2327-E2330 and both the interface (e.g., joystick, head control, sip and puff), and the controller electronics are being replaced due to irreparable damage.

(n) Other power wheelchair accessories. An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface may be covered if the client has a covered speech generating device (See chapter 410, division 129, Speech-Language Pathology, Audiology and Hearing Aid Services.);

(o) Miscellaneous accessories:

(A) Anti-rollback device (E0974) is covered if the client propels himself and needs the device because of ramps;

(B) A safety belt/pelvic strap (E0978) is covered if the client has weak upper body muscles, upper body instability, or muscle spasticity that requires use of this item for proper positioning;

(C) A shoulder harness/straps or chest strap (E0960) and a safety belt/pelvic strap (E0978) are covered only to treat a client’s medical symptoms:

(i) A medical symptom is defined as an indication or characteristic of a physical or psychological condition;

(ii) E0960 and E0978 are not covered when intended for use as a physical restraint or for purposes intended for discipline or convenience of others.

(D) One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028, E1032, E1033, or E1034) may be to move the component out of the way so that a client could perform a slide transfer to a chair or bed;

(E) A manual fully reclining back option (E1226) is covered if the client spends at least two (2) hours per day in the wheelchair and has one or more of the following conditions:

(i) The client is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

(ii) The client utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed;

(iii) Trunk or lower extremity casts/braces that require the reclining back feature for positioning;

(iv) Excess extensor tone of the trunk muscles; or

(v) The need to rest in a recumbent position two or more times during the day, and transfer between wheelchair and bed is very difficult.

(F) A power standing system (E2301) is covered if the client spends at least two (2) hours per day in the wheelchair, requires supported standing to address one or more the following areas (i – viii) and criteria (ix – xiii) are met:

(i) Maintain or improve bladder function; or

(ii) Maintain or promote bone/joint health; or

(iii) Maintain or improve bowel and/or bladder function; or

(iv) Maintain or improve digestive process; or

(v) Maintain or promote cardiac function; or

(vi) Management of contractures and range of motion in the lower extremities; or

(vii) Management of pain associated with spasticity or tone; or

(viii) Reduced respiratory function secondary to inability to independently achieve an upright posture; and

(ix) Effective weight bearing cannot be achieved by any other means; and

(x) Unable to stand without external support; and

(xi) Able to move to/from a seated and standing position by mechanical means; and

(xii) Demonstrated tolerance for standing and at least partial weight bearing; and

(xiii) Moving in a standing position is required to perform or participate in MRADLs.

(2) Documentation Requirements. Submit documentation that supports coverage criteria in this rule are met and the specified information as follows with the prior authorization (PA) request:

(a) When code K0108 is billed, a narrative description of the item, the manufacturer, the model’s name or number (if applicable), and information justifying the medical appropriateness for the item;

(b) Options/accessories for individual consideration might include documentation on the client's diagnosis, the client's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the client performs, etc.), the duration of the condition, the expected prognosis, past experience using similar equipment;

(A) A comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise paid by a DMEPOS provider) that clearly explains why a prefabricated seating system is not sufficient to meet the client's seating and positioning needs;

(B) Diagnostic reports that support the medical condition;

(D) Body contour measurements.

(d) Documentation that the coverage criteria in this rule have been met must be present in the client’s medical record. This documentation and any additional medical information from the DMEPOS provider must be made available to the Division upon request.

(3) Table 122-0340 – 1.

(4) Table 122-0340 – 2.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 10-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 17-2012, f. 3-30-12, cert. ef. 4-1-12
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0360 Canes and Crutches

(1) Indications and Coverage: When prescribed by a practitioner for a client with a condition causing impaired ambulation and there is a potential for ambulation.

(2) A white cane for a visually impaired client is considered to be a self-help item and is not covered by the Division.

(3) Table 122-0360.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 11-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0365 Standing and Positioning Aids

(1) Indications and limitations of coverage and medical appropriateness: Standing frame systems, prone standers, supine standers or boards, and accessories may be covered by the Division when conditions of coverage in OAR 410-122-0080 and the following criteria are met:

(a) The client is unable to stand or ambulate independently due to conditions such as, but not limited to, neuromuscular or congenital disorders, including acquired skeletal abnormalities;

(b) The client is at high risk for lower extremity contractures that cannot be appropriately managed by other treatment modalities (i.e., stretching, active therapy, home programs, etc)

(c) The client has been sequentially evaluated by a physical or occupational therapist to make certain the client can tolerate a standing or upright position and obtain medical benefit; and,

(d) The client is following a home therapy program for the stander established by a physical or occupational therapist; and

(e) The home is able to accommodate the equipment; and

(f) The weight of the client does not exceed manufacturer’s weight capacity; and

(g) The client has demonstrated an ability to utilize the standing aid independently or with assistance from a caregiver; and

(h) The client has demonstrated compliance with other programs; and

(i) The client has demonstrated a successful clinical evaluation or trial period in a monitored setting; and

(j) The client does not have access to equipment from another source.

(2) Sidelyers and custom positioners shall meet the following criteria in addition to the criteria in Table 122-0365:

(a) The client shall be sequentially evaluated by a physical or occupational therapist to make certain the client can tolerate and obtain medical benefit; and

(b) The client shall be following a therapy program initially established by a physical or occupational therapist; and,

(d) The caregiver or family are capable of using the equipment appropriately.

(3) Criteria for Specific Accessories:

(a) A back support may be covered when a client:

(A) Needs balance, stability, or positioning assistance; or

(B) Has extensor tone of the trunk muscles; or

(b) A tall back may be covered when:

(A) The client is over 5’11” tall; and

(B) The client has no trunk control and needs additional support; or

(A) Lacks motor control or strength to center hips; or

(B) Has asymmetrical tone that causes hips to pull to one side; or

(D) Has low tone or high tone; or

(E) Needs balance, stability, or positioning assistance;

(d) A shoulder retractor or harness may be covered when:

(A) Erect posture cannot be maintained without support due to lack of motor control or strength; or

(B) Has kyphosis; or

(e) Lateral supports may be covered when a client:

(A) Lacks trunk control to maintain lateral stability; or

(B) Has scoliosis that requires support; or

(f) A headrest may be covered when a client:

(A) Lacks head control and cannot hold head up without support; or

(B) Has strong extensor thrust pattern that requires inhibition;

(g) Independent adjustable knee pads may be covered when a client:

(A) Has severe leg length discrepancy; or

(B) Has contractures in one leg greater than the other;

(h) An actuator handle extension may be covered when a client:

(A) Has no caregiver; and

(B) Is able to transfer independently into standing frame; and

(i) Arm troughs may be covered when a client:

(A) Has increased tone that pulls arms backward so hands cannot come to midline; or

(B) Has poor tone, strength, or control that causes arms to hang out to side and backward causing pain and risking injury; or

(j) A tray may be covered when proper positioning cannot be accomplished with other accessories;

(k) Abductors may be covered to reduce tone for proper alignment and weight bearing;

(l) Sandals (shoe holders) may be covered when a client:

(A) Has dorsiflexion of the foot or feet; or

(B) Has planar flexion of the foot or feet; or

(D) Has need for safety.

(4) If a client has one aid that meets medical needs, regardless of who obtained it, the Division may not provide another aid of same or similar function.

(5) Gait Belts (E0700) shall be covered when:

(a) The client weighs 60 lbs. or more; and

(b) The care provider is trained in the proper use; and

(A) A minor correction of ambulation; or

(B) Minimal or standby assistance to walk alone; or

(6) For services requiring prior authorization (PA), submit the following documentation to support coverage criteria in this rule are met:

(a) Documentation of medical appropriateness, which has been reviewed and signed by the prescribing practitioner;

(b) The care plan outlining positioning and treatment regimen and all DME currently available for use by the client;

(d) Each item requested shall be itemized with description of product, make, model number, and manufacturers’ suggested retail price (MSRP);

(e) The Positioner Justification form (DMAP 3155) or reasonable facsimile with recommendation for most appropriate equipment completed by the prescribing practitioner or the evaluating PT or OT;

(7) Providers shall use the appropriate HCPCS code assigned to the standing system base (e.g., E0637, E0638, E0641, and E0642).

(8) Providers shall use E1399 for standing frame accessories when billing separately from the base. PA is required when the billed charge for the accessory is greater than $150.

(9) PDAC coding verification is not required on standing frame equipment and accessories as this is statutorily excluded from Medicare coverage and as such does not have an assigned HCPCS code.

(10) Documentation and medical records to support the client meets all criteria and conditions of coverage in this rule must be kept on file with the DMEPOS provider and shall be made available to the Division upon request.

(11) Table 122-0365.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 12-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0375 Walkers

(1) Indications and Limitations of Coverage:

(a) A standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if both of the following criteria are met:

(A) When prescribed by a treating practitioner for a client with a medical condition impairing ambulation and there is a potential for increasing ambulation; and

(B) When there is a need for greater stability and security than provided by a cane or crutches;

(b) For an adult gait trainer, use the appropriate walker code. If a gait trainer has a feature described by one of the walker attachment codes (E0154-E0157), that code may be separately billed;

(c) A heavy duty walker (E0148, E0149) is covered for clients who meet coverage criteria for a standard walker and who weigh more than 300 pounds

(d) A heavy duty, multiple braking system, variable wheel resistance walker (E0147) is covered for clients who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand;

(e) When a walker with an enclosed frame (E0144) is dispensed to a client, documentation must support why a standard folding wheeled walker, E0143, was not provided as the least costly medically appropriate alternative;

(f) Enhancement accessories of walkers are non-covered;

(g) Leg extensions (E0158) are covered only for patients six feet tall or more.

(2) Coding Guidelines:

(a) A wheeled walker (E0141, E0143, E0149) is one with either two, three or four wheels. It may be fixed height or adjustable height. It may or may not include glide-type brakes (or equivalent). The wheels may be fixed or swivel;

(b) A glide-type brake consists of a spring mechanism (or equivalent) which raises the leg post of the walker off the ground when the patient is not pushing down on the frame;

(c) Code E0144 describes a folding wheeled walker which has a frame that completely surrounds the patient and an attached seat in the back;

(d) A heavy duty walker (E0148, E0149) is one which is labeled as capable of supporting patients who weigh more than 300 pounds. It may be fixed height or adjustable height. It may be rigid or folding;

(e) Code E0147 describes a 4-wheeled, adjustable height, folding-walker that has all of the following characteristics:

(A) Capable of supporting patients who weigh greater than 350 pounds;

(B) Hand operated brakes that cause the wheels to lock when the hand levers are released;

(D) The pressure required to operate each hand brake is individually adjustable;

(E) There is an additional braking mechanism on the front crossbar;

(F) At least two wheels have brakes that can be independently set through tension adjustability to give varying resistance;

(f) The only walkers that may be billed using code E0147 are those products listed in the Product Classification List on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor’s web site;

(g) An enhancement accessory is one which does not contribute significantly to the therapeutic function of the walker. It may include, but is not limited to style, color, hand operated brakes (other than those described in code E0147), or basket (or equivalent);

(h) A4636, A4637, and E0159 are only used to bill for replacement items for covered, patient-owned walkers. Codes E0154, E0156, E0157, and E0158 can be used for accessories provided with the initial issue of a walker or for replacement components. Code E0155 can be used for replacements on covered, patient-owned wheeled walkers or when wheels are subsequently added to a covered, patient-owned non-wheeled walker (E0130, E0135). Code E0155 cannot be used for wheels provided at the time of, or within one month of, the initial issue of a non-wheeled walker;

(i) Hemi-walkers must be billed using code E0130 or E0135, not E1399;

(j) A gait trainer is a term used to describe certain devices that are used to support a client during ambulation. Gait trainers are billed using one of the codes for walkers. If a gait trainer has a feature described by one of the walker attachment codes (E0154, E0155, E0157) that code may be separately billed. Other unique features of gait trainers are not separately payable and may not be billed using E1399;

(k) Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code: See attached Table 122-0375-1

(L) Providers shall contact PDAC for guidance on the correct coding of these items.

(3) Documentation: An order for each item billed must be signed and dated by the treating practitioner, kept on file by the DMEPOS provider, and made available to the Division upon request. The treating practitioner’s records must contain information that supports the medical appropriateness of the item ordered, including height and weight.

(4) Table 122-0375-1.

(5) Table 122-0375-2.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 13-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0380 Hospital Beds

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover a hospital bed when conditions of coverage in OAR 410-122-0080 and the following criteria are met:

(a) A fixed height hospital bed (E0250, E0251, E0290, E0291, E0328) when the client meets at least one (1) of the following criteria:

(A) Has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed;

(B) Requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain;

(C) Requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges shall have been considered and ruled out;

(D) Requires traction equipment that can only be attached to a hospital bed;

(b) A variable height hospital bed (E0255, E0256, E0292 and E0293) when all of the following criteria are met:

(A) Criteria for a fixed height hospital bed are met;

(B) A bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair, or standing position is required;

(A) Criteria for a fixed height hospital bed are met;

(B) Frequent changes or an immediate need for a change in body position are required;

(d) A heavy duty extra wide hospital bed (E0301, E0303) when all of the following criteria are met:

(A) Criteria for a fixed height hospital bed are met;

(B) The client weighs more than 350 pounds but less than 600 pounds;

(e) An extra heavy duty hospital bed (E0302, E0304) when all of the following are met:

(A) Criteria for one of the hospital beds described in (1)(a)-(d) are met;

(B) The client weighs more than 600 pounds;

(D) When provided for a nursing facility client, the bed shall be rated for institutional use;

(f) Total electric hospital beds (E0265, E0266, E0296, E0297, and E0329) are reviewed on a case-by-case basis to determine if the client’s documentation supports the height adjustment feature is medically necessary and medically appropriate for the treatment of the client’s condition;

(g) No prior authorization (PA) is required for the initial two (2) months rental of a hospital bed unless otherwise specified in this rule (2)(b) and (d). The DMEPOS provider is responsible to ensure all requirements in this rule are met.

(2) PA Required: PA is obtained from the same authorizing authority as specified in OAR 410-122-0040 and required for the following services:

(a) Initial purchase or subsequent rentals of a hospital bed starting with the third (3rd) month date of service;

(b) Total electric hospital beds starting with the first (1st) month rental or upon initial purchase;

(c) Replacement of a hospital bed during the five (5) year reasonable useful lifetime due to loss, theft, or irreparable damage;

(d) Enclosed safety beds starting with the first (1st) month rental or upon initial purchase. Refer to the Division’s policy for criteria and coverage guidelines: https://www.oregon.gov/oha/HSD/OHP/Announcements/Safety-Bed-Policy1124.pdf.

(3) Documentation requirements:

(a) For services requiring prior authorization, submit documentation that supports coverage criteria specified in this rule are met, including:

(A) For all hospital beds:

(i) Primary diagnosis code for the condition necessitating the need for a hospital bed;

(ii) The type of bed currently used by the client and why it doesn’t meet the medical needs of the client;

(B) For semi-electric beds: Why a variable height bed cannot meet the medical needs of the client;

(4) Table 122-0380 — Hospital Beds.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 14-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0400 Pressure Reducing Support Surfaces

(1) Indications and limitations of coverage and medical appropriateness:

(a) Group 1 (A4640, E0181–E0182, E0184–E0189, and E0196-E0199):

(A) The Division may cover a Group 1 support surface when the client meets:

(i) Criterion (I), or;

(ii) Criteria (II) or (III) and at least one of criteria (IV)–(VII):

(I) Completely immobile — i.e., client cannot make changes in body position without assistance;

(II) Limited mobility — i.e., client cannot independently make changes in body position significant enough to alleviate pressure;

(III) Any stage pressure ulcer on the trunk or pelvis;

(IV) Impaired nutritional status;

(V) Fecal or urinary incontinence;

(VI) Altered sensory perception;

(VII) Compromised circulatory status;

(B) The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) provider must provide a support surface in which the client does not "bottom out";

(C) The Division does not cover foam overlays or mattresses without a waterproof cover, since these are not considered durable;

(D) The Division does not cover pressure reducing support surfaces for the prevention of pressure ulcers or pain control;

(E) The allowable rental fee includes all equipment, supplies and services for the effective use of the pressure reducing support surface;

(b) Group 2 (E0193, E0277, and E0371–E0373):

(A) A Group 2 support surface may be covered for up to an initial three month rental period when the client meets:

(i) Criterion (I) and (II) and (III), or;

(ii) Criterion (IV), or;

(iii) Criterion (V) and (VI);

(I) Multiple stage II pressure ulcers located on the trunk or pelvis;

(II) Client has been on a comprehensive ulcer treatment program for at least the past month which includes the following: use of an appropriate Group 1 support surface; education of the client, if appropriate, and caregiver on the prevention and/or management of pressure ulcers; regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer); appropriate turning and positioning; appropriate wound care (for a stage II, III, or IV ulcer); appropriate management of moisture/incontinence; and nutritional assessment and intervention consistent with the overall plan of care;

(III) The ulcers have worsened or remained the same over the past month;

(IV) Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis A large wound is generally any wound of eight square centimeters (length x width) or more. Individual client circumstances may be weighed. Undermining and/or tunneling, anatomic location on the body and the size of the client may be taken into account;

(V) Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days)

(VI) The client has been on a Group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days);

(B) The DMEPOS provider must provide a support surface in which the patient does not "bottom out";

(C) When a Group 2 surface is requested following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery

(D) The Division may cover continued use of a Group 2 support surface if healing continues;

(E) The Division does not cover pressure reducing support surfaces for the prevention of pressure ulcers or pain control;

(F) The allowable rental fee includes all equipment, supplies and services for the effective use of the pressure reducing support surface;

(c) Division may consider coverage for bariatric pressure reducing support surfaces only coded as E1399 (durable medical equipment, miscellaneous) for a client residing in a nursing facility, subject to service limitations of Division rules, only when the following requirements are met:

(A) The client meets the conditions of coverage as specified in this rule; and

(B) The bariatric pressure reducing support surface has been assigned code E1399 by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor;

(d) Group 3: Air-fluidized beds (E0194) are not covered.

(2) Definitions for Group 1 and Group 2:

(a) Bottoming out: Finding that an outstretched hand, placed palm up between the undersurface of the overlay or mattress and the patient's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion shall be tested with the client in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side-lying position;

(b) Plan of care: Written guidelines developed to identify specific problems and needs of the client and interventions/regimen necessary to assist the client to achieve optimal health potential. Developing the plan of care includes establishing measurable client and nursing goals with time lines and determining nursing/caregiver/other discipline-assigned interventions to meet care objectives;

(A) Stage I — Observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues;

(B) Stage II — Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater;

(C) Stage III — Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue;

(D) Stage IV — Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers;

(3) Guidelines:

(a) Group 1:

(A) Codes E0185 and E0197–E0199 termed "pressure pad for mattress" describe non-powered pressure reducing mattress overlays and are designed to be placed on top of a standard hospital or home mattress;

(B) A gel/gel-like mattress overlay (E0185) is characterized by a gel or gel-like layer with a height of two inches or greater;

(C) An air mattress overlay (E0197) is characterized by interconnected air cells having a cell height of three inches or greater that are inflated with an air pump;

(D) A water mattress overlay (E0198) is characterized by a filled height of three inches or greater;

(E) A foam mattress overlay (E0199) is characterized by all of the following:

(i) Base thickness of two inches or greater and peak height of three inches or greater if it is a convoluted overlay (e.g., egg crate) or an overall height of at least three inches if it is a non-convoluted overlay; and

(ii) Foam with a density and other qualities that provide adequate pressure reduction; and

(iii) Durable, waterproof cover;

(F) Codes E0184, E0186, E0187 and E0196 describe non-powered pressure reducing mattresses;

(G) A foam mattress (E0184) is characterized by all of the following:

(i) Foam height of five inches or greater;

(ii Foam with a density and other qualities that provide adequate pressure reduction;

(iii) Durable, waterproof cover; and

(iv) Can be placed directly on a hospital bed frame;

(H) An air, water or gel mattress (E0186, E0187, E0196) is characterized by all of the following:

(i) Height of five inches or greater of the air, water, or gel layer (respectively);

(ii) Durable, waterproof cover; and

(iii) Can be placed directly on a hospital bed frame;

(I) Codes E0181, E0182, and A4640 describe powered pressure reducing mattress overlay systems (alternating pressure or low air loss) and are characterized by all of the following:

(i) An air pump or blower which provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay;

(ii) Inflated cell height of the air cells through which air is being circulated is 2 inches or greater; and

(iii) Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate client lift, reduce pressure and prevent bottoming out;

(J) Alternating pressure mattress overlays or low air loss mattress overlays are coded using codes E0181, E0182, and A4640;

(K) Code A4640 or E0182 may only be billed when they are provided as replacement components for a client-owned E0181 mattress overlay system;

(L) A Column II code is included in the allowance for the corresponding Column I code when provided at the same time: Column I (Column II), E0181 (A4640, E0182);

(b) Group 2:

(A) Code E0277 describes a powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) which is characterized by all of the following:

(i) An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress;

(ii) Inflated cell height of the air cells through which air is being circulated is five inches or greater;

(iii) Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming out;

(iv) A surface designed to reduce friction and shear; and

(v) Can be placed directly on a hospital bed frame;

(B) Code E0193 describes a semi-electric or total electric hospital bed with a fully integrated powered pressure reducing mattress which has all the characteristics defined above;

(C) Code E0371 describes an advanced non-powered pressure-reducing mattress overlay which is characterized by all of the following:

(i) Height and design of individual cells which provide significantly more pressure reduction than a group 1 overlay and prevent bottoming out;

(ii) Total height of three inches or greater;

(iii) A surface designed to reduce friction and shear; and

(iv) Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces;

(D) Code E0372 describes a powered pressure reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure) which is characterized by all of the following:

(i) An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay;

(ii) Inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater;

(iii) Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate patient lift, reduce pressure and prevent bottoming out; and

(iv) A surface designed to reduce friction and shear;

(E) Code E0373 describes an advanced non-powered pressure reducing mattress which is characterized by all of the following:

(i) Height and design of individual cells which provide significantly more pressure reduction than a group 1 mattress and prevent bottoming out;

(ii) Total height of five inches or greater;

(iii) A surface designed to reduce friction and shear;

(iv) Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces; and

(v) Can be placed directly on a hospital bed frame;

(F) The only products that may be coded and billed using code E0371 or E0373 are those products for which a written coding determination specifying the use of these codes has been made by PDAC;

(G) Alternating pressure mattresses and low air loss mattresses are coded using code E0277;

(H) Products containing multiple components are categorized according to the clinically predominant component (usually the topmost layer of a multi-layer product). For example, a product with three powered air cells on top of a three foam base would be coded as a powered overlay (code E0181), not as a powered mattress (E0277).

(4) Documentation requirements: Submit the following information with the prior authorization request:

(a) Initial Requests:

(A) For all pressure reducing support surfaces, other than a Group I for a completely immobile client or a Group 2 surface following a myocutaneous flap or skin graft:

(i) An order for each item requested, signed and dated by the attending practitioner;

(ii) Documentation that supports conditions of coverage are met as specified in this rule;

(iii) A plan of care which has been established by the client's practitioner or home care nurse (by the RN resident care manager for a client in a nursing facility), which generally includes the following:

(I) Education of the client, if appropriate, and caregiver on the prevention and/or management of pressure ulcers;

(II) Regular assessment by a nurse, physician, or other licensed healthcare practitioner;

(III) Appropriate turning and positioning including the number of hours per 24-period that the client will utilize the support surface;

(IV) Appropriate wound care (for a stage II, III, or IV ulcer);

(V) Appropriate management of moisture/incontinence;

(VI) Nutritional assessment and intervention consistent with the overall plan of care by a licensed healthcare practitioner (by a registered dietitian for a client in a nursing facility) within the last 90 days;

(VII) Client’s weight and height (approximation is acceptable, if unable to obtain);

(VIII) Description of all pressure ulcers, which includes number, locations, stages, sizes and dated photographs;

(iv) Lab reports, if relevant;

(v) Other treatments and products that have been tried and why they were ineffective; Interventions and goals for stepping down the intensity of support surface therapy;

(vi) For pressure ulcers on extremities, why pressure cannot be relieved by other methods;

(B) For a Group I surface for a completely immobile client:

(i) An order for each item requested, signed and dated by the attending practitioner;

(ii) A plan of care which has been established by the client's practitioner or home care nurse (by the RN resident care manager for a client in a nursing facility), which generally includes the following:

(I) Education of the client, if appropriate, and caregiver on the prevention of pressure ulcers;

(II) Regular assessment by a nurse, physician, or other licensed healthcare practitioner

(III) Appropriate turning and positioning including the number of hours per 24-period that the client will utilize the support surface;

(IV) Appropriate management of moisture/incontinence, if appropriate;

(i) An order for each item requested, signed and dated by the treating practitioner;

(ii) Operative report;

(iii) Hospital discharge summary;

(iv) Plan of care;

(F) Required documentation may not be completed by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider or anyone in a financial relationship of any kind with the DMEPOS provider;

(G) Medical records must corroborate that all criteria in this rule are met when dispensing and billing for an item in Table 122-0400-1 and Table-122-400-2;

(H) Medical records must be kept on file by the DMEPOS provider and made available to the Division upon request;

(b) Subsequent Requests: May be authorized contingent on progress towards healing:

(A) For all pressure reducing support surfaces, other than a Group I surface for a completely immobile client or a Group 2 surface following a myocutaneous flap or skin graft:

(i) Progress notes from the attending practitioner;

(ii) Description of all pressure ulcers, including progress towards healing, by a licensed healthcare practitioner (by the RN resident care manager for a client in a nursing facility) which includes number, locations, stages, sizes and dated photographs;

(iii) Current plan of care;

(iv) Any other relevant documentation;

(B) For a Group I surface for a completely immobile client:

(i) Progress notes from the attending practitioner;

(ii) Current plan of care;

(iii) Any other relevant documentation;

(i) Progress notes from the attending practitioner;

(ii) Current plan of care;

(iii) Any other relevant documentation.

(4) Table 122-0400-1 — Group 1.

(5) Table 122-0400-2 — Group 2.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 15-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 61-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0420 Hospital Bed Accessories

(1) Table 122-0420, Hospital Bed Accessories Procedure codes — Trapeze Bars:

(a) Indications and coverage: Trapeze bars are indicated when a client needs this device to sit up because of respiratory condition, to change body position for other medical reasons, or to get in or out of bed;

(b) The Division may consider coverage for bariatric trapeze bars only coded as E1399 (durable medical equipment, miscellaneous) for a client residing in a nursing facility), subject to service limitations of Division rules, only when the following requirements are met:

(A) The client meets the conditions of coverage as specified in this rule; and

(B) The bariatric trapeze bar has been assigned code E1399 by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor;

(c) Documentation of medical appropriateness which has been reviewed and signed by the prescribing practitioner must be kept on file by the DME provider;

(2) See Table 122-0420 for procedure codes.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
HR 17-1996, f. & cert. ef. 8-1-96
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0475 Therapeutic Shoes for Diabetics

(1) Indications and Coverage:

(a) For each client, coverage of the footwear and inserts is limited to one of the following within one calendar year:

(A) One pair of custom-molded shoes (including inserts provided with such shoes) and two additional pair of inserts; or

(B) One pair of extra-depth shoes (not including inserts provided with such shoes) and three pairs of inserts.

(b) An individual may substitute modification of custom molded or extra-depth shoes instead of obtaining one pair of inserts, other than the initial pair of inserts. The most common shoe modifications are:

(A) Rigid rocker bottoms;

(B) Roller bottoms;

(D) Wedges;

(E) Offset heels.

(d) Payment for the certification of the need for therapeutic shoes and for the prescription of the shoes (by a different practitioner from the one who certifies the need for the shoes) is considered to be included in the visit or consultation in which these services are provided;

(e) Following certification by the practitioner managing the client’s systemic diabetic condition, a podiatrist or other qualified practitioner knowledgeable in the fitting of the therapeutic shoes and inserts may prescribe the particular type of footwear necessary.

(2) Documentation:

(a) The practitioner who is managing the individual’s systemic diabetic condition documents that the client has diabetes and one or more of the following conditions:

(A) Previous amputation of the other foot or part of either foot;

(B) History of previous foot ulceration of either foot;

(D) Peripheral neuropathy with evidence of callus formation of either foot;

(E) Foot deformity of either foot; or

(F) Poor circulation in either foot; and

(G) Certifies that the client is being treated under a comprehensive plan of care for his or her diabetes and that he or she needs therapeutic shoes;

(b) Documentation of the above criteria may be completed by the prescribing practitioner or supplier but shall be reviewed for accuracy and signed and dated by the certifying practitioner to indicate agreement and shall be kept on file by the DME supplier.

(3) Table 122-0475.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 16-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 62-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0510 Osteogenesis Stimulator

(1) Definitions:

(a) An electrical osteogenesis stimulator is a device that provides electrical stimulation to augment bone repair;

(b) A noninvasive electrical stimulator is characterized by an external power source that is attached to a coil or electrodes placed on the skin or on a cast or brace over a fracture or fusion site;

(c) An ultrasonic osteogenesis stimulator is a noninvasive device that emits low intensity, pulsed ultrasound signals to stimulate fracture healing. The device is applied to the surface of the skin at the fracture site and ultrasound waves are emitted via conductive coupling gel to stimulate fracture healing;

(2) Indications of coverage and medical appropriateness:(a) Non-spinal Electrical Osteogenesis Stimulator:

(a) The Division may cover a non-spinal electrical osteogenesis stimulator (E0747) when any of the following criteria are met:

(A) Non-union of a long bone fracture (defined as radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator); or

(B) Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery; or

(i) Non-union of a long bone fracture shall be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site and with a written interpretation by the treating practitioner stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs;

(ii) A long bone is limited to a clavicle, humerus, radius, ulna, femur, tibia, fibula, metacarpal or metatarsal.

(b) Spinal Electrical Osteogenesis Stimulator:

(A) The Division may cover a spinal electrical osteogenesis stimulator (E0748) when any of the following criteria are met:

(i) Failed spinal fusion where a minimum of nine months has elapsed since the last surgery; or

(ii) Following a multilevel spinal fusion surgery; or

(iii) Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same site;

(B) A multilevel spinal fusion involves three or more vertebrae (e.g., L3-L5, L4-S1, etc.);

(A) The Division may cover an ultrasonic osteogenesis stimulator (E0760) only when all of the following criteria are met:

(i) Non-union of a fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenic stimulator, each separated by a minimum of 90 days. Each radiograph shall include multiple views of the fracture site accompanied by a written interpretation by the treating practitioner stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs; and

(ii) The stimulator is intended for use prior to surgical intervention and with cast immobilization;

(B) Use of an ultrasonic osteogenic stimulator is not covered:

(i) For non-union fractures of the skull or vertebrae;

(ii) For tumor-related fractures;

(iii) For the treatment of a fresh fracture or delayed union; or

(iv) When used concurrently with other noninvasive osteogenic devices;

(C) The Division may cover ultrasonic conductive coupling gel as a separate service when an ultrasonic osteogenesis stimulator is covered.

(3) Coding guidelines: Use A4559 for ultrasonic conductive coupling gel.

(4) Documentation requirements:

(a) Submit the following with the PA request:

(A) Documentation that supports the coverage criteria specified in this rule for the stimulator requested are met;

(B) Copies of x-ray and operative reports;

(b) Additional medical records may be requested by the Division;

(c) The client’s medical records shall reflect the need for the stimulator requested. The client’s medical records include, but are not limited to, the practitioner’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals, and test/diagnostic reports.

(5) Table 122-0510.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 17-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92

Or. Admin. R. 410-122-0515 Neuromuscular Electrical Stimulator (NMES)

Indications and limitations of coverage and medical appropriateness: The Division may cover a neuromuscular electrical stimulator (NMES) that uses electrodes to transmit an electrical impulse to the skin over selected muscle groups. There are two (2) broad categories of NMES:

(1) One type of NMES is for treatment of muscle atrophy;

(a) In this category, the NMES device stimulates the muscle when the client is in a resting state to treat muscle atrophy;

(b) The Division shall cover this type of NMES to treat muscle atrophy specific to disuse atrophy where nerve supply to the muscle is intact (including brain, spinal cord and peripheral nerves) and to treat other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins).

(2) The second type of NMES is commonly referred to as functional electrical stimulation (FES). FES devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence.

(a) In this category, the FES device is used to enhance functional activity of neurologically impaired clients. FES devices used to improve the ability to walk in clients with spinal cord injury (SCI) shall be covered;

(b) The Division shall only cover FES for SCI clients for walking, who meet the following criteria:

(A) Client has completed at least thirty-two (32) physical therapy sessions, directly performed one-on-one with the physical therapist with the device over a trial period of three (3) months, with the specific goal of using the FES device to achieve walking, not to reverse or retard muscle atrophy;

(B) Therapists with the sufficient skills to provide these services are only employed at inpatient hospitals; outpatient hospitals; comprehensive outpatient rehabilitation facilities; and outpatient rehabilitation facilities;

(C) The practitioner treating the client for SCI will use this trial period to properly evaluate the person's ability to use the FES frequently and for the long term; and

(D) The client meets all of the following characteristics:

(i) Intact lower motor units (L1 and below) (both muscle and peripheral nerve);

(ii) Muscle and joint stability for weight bearing at upper and lower extremities that demonstrates balance and control to maintain an upright support posture independently;

(iii) Demonstrated brisk muscle contraction to NMES and sensory perception of electrical stimulation sufficient for muscle contraction;

(iv) High motivation, commitment and cognitive ability to use FES devices for walking;

(v) Can transfer independently and demonstrates independent standing tolerance for at least three (3) minutes;

(vi) Demonstrated hand and finger function to manipulate controls;

(vii) At least six (6) month post recovery spinal cord injury and restorative surgery;

(viii) Hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and

(ix) Demonstrated willingness to use the device long-term.

(3) FES for walking is contraindicated for a SCI client with any of the following:

(a) Cardiac pacemaker;

(b) Severe scoliosis or severe osteoporosis;

(d) Irreversible contracture; or

(e) Autonomic dysflexia;

(4) The requested system or device shall either be approved, registered, or listed as a medical device with the Food and Drug Administration (FDA) and otherwise generally considered to be safe and effective for the intended purpose.

(5) Documentation requirements:

(a) Submit the following documentation for prior authorization (PA) review:

(A) An order from the treating practitioner;

(B) Documentation of signs/symptoms/medical condition exhibited by the client that clearly specifies the medical appropriateness and medical necessity for the device;

(6) Procedure codes:

(a) The Medicare Pricing, Data Analysis and Coding contractor is responsible for assisting DMEPOS providers and manufacturers in determining which HCPCS code shall be used to describe DMEPOS items;

(b) Refer to the product classification list on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor website for appropriate Healthcare Common Procedure Coding System (HCPCS) codes.

(A) E0745, Neuromuscular stimulator, electronic shock unit — Division shall rent — Purchased after no more than 10 months of rental — PA required.

(B) A4595, Electrical stimulator supplies, two (2) lead, per month, (e.g. TENS, NMES) — Includes all supplies necessary for the effective use of the device — Division shall purchase;

(d) FES:

(A) E0764, Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program; — Division shall rent — Purchased after no more than 10 months of rental — PA required.

(B) E0770 – Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified — Division shall rent — Purchased after no more than 10 months of rental — PA required.

(C) A4595, Electrical stimulator supplies, two (2) lead, per month/one (1) unit (e.g. FES, NMES) — Includes all supplies necessary for the effective use of the device. Not reimbursable with initial purchase. If medically necessary, a maximum of two (2) units per month (4 leads) is allowed.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 70-2023, minor correction filed 08/19/2023, effective 08/19/2023
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06

Or. Admin. R. 410-122-0520 Glucose Monitors and Diabetic Supplies

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover home blood glucose monitors and related diabetic supplies for clients with diabetes who can self-monitor blood glucose (SMBG) or be monitored with assistance;

(b) Coverage of home blood glucose monitors is limited to clients meeting all of the following conditions:

(A) The client has diabetes that is being treated by a practitioner; and

(B) The glucose monitor and related accessories and supplies have been ordered by a practitioner who is treating the client’s diabetes; and

(C) The client or caregiver has successfully completed a structured education and feedback program for self-monitoring of blood glucose and is scheduled to begin training in the use of the monitor, test strips, and lancing devices; and

(D) The client or caregiver is capable of using the test results to assure the client’s appropriate glycemic control; and

(E) The device is designed for home use;

(c) Home blood glucose monitors with special features (E2100 or E2101) may be covered for clients who meet the basic coverage criteria (1)(b)(A)–(E) of this rule and the following:

(A) For code E2100, the treating practitioner certifies that the client has a severe visual impairment (i.e., best corrected visual acuity of 20/200 or worse) requiring use of this special monitoring system; or

(B) For code E2101, the treating practitioner certifies that the client has an impairment of manual dexterity severe enough to require the use of this special monitoring system;

(d) If a glucose monitor is covered, lancets, blood glucose test reagent strips, glucose control solutions, insulin syringes, and spring powered devices for lancets may also be covered. Coverage limitations for these supplies are as follows:

(A) For A4258, only one spring powered device every six months;

(B) For A4253 and A4259, the provider of the test strips and lancets shall maintain in their records the order from the treating practitioner. The provider shall verify that the client has nearly exhausted their supply, before dispensing more test strips and lancets. The amount of test strips and lancets covered is based on the needs of the client according to the following limitations:

(i) For clients with type 2 diabetes not requiring multiple daily insulin injections, up to 50 test strips (1 unit) and 100 lancets (1 unit) at the time of diagnosis;

(ii) For clients with type 2 diabetes who require diabetic medication that may result in hypoglycemia, up to 50 test strips and 100 lancets per 90 days. An additional 50 test strips may be covered with clinical documentation of an acute change in glycemic control or active diabetic medication adjustment;

(iii) For clients with Type 1 diabetes and those with type 2 diabetes requiring multiple daily insulin injections, up to 100 test strips and 100 lancets per month;

(iv) For clients with gestational diabetes, up to 150 test strips and 200 lancets per month no longer than 60 days beyond the duration of the pregnancy;

(v) Quantities exceeding these utilization guidelines require prior authorization and may be covered when:

(I) Basic coverage criteria in (1)(b)(A)-(E) for home glucose monitors and related accessories and supplies are met; and

(II) The treating practitioner has seen the client and evaluated their diabetes control within six months prior to ordering quantities of test strips and lancets that exceed the utilization guidelines and has documented in the client’s medical record the specific reason for the additional supplies for that particular client; and

(III) If refills of quantities of supplies that exceed utilization guidelines are dispensed, there shall be documentation in the practitioner’s records (e.g., a specific narrative statement that adequately specifies the frequency at which the client is actually testing or a copy of the client's log) that the client is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the client is regularly using quantities of supplies that exceed the utilization guidelines, new documentation shall be present at least every six months;

(e) Diabetic supply providers may not dispense a quantity of supplies exceeding a client’s expected utilization. Providers shall stay attuned to atypical utilization patterns on behalf of their clients and verify with the ordering practitioner that the atypical utilization is, in fact, warranted. Regardless of utilization, a provider may not dispense more than a three-month quantity of glucose testing supplies (i.e., up to 300 test strips, 300 lancets, and 500 insulin syringes) at a time. Prior authorization (PA) shall be obtained prior to dispensing amounts in excess of these utilization limits;

(f) Providers may contact the treating practitioner to renew an order; however, the request for renewal may only be made with the client’s continued monthly use of testing supplies and only with the client’s or caregiver’s request to the provider for order renewal;

(g) An order refill does not have to be approved by the ordering practitioner; however, a client or their caregiver shall specifically request refills of glucose monitor supplies before they are dispensed. The provider may not automatically dispense a quantity of supplies on a predetermined regular basis, even if the client has "authorized" this in advance;

(h) Purchase fee for a glucose monitor includes normal, low and high-calibrator solution/chips (A4256), a battery (A4233, A4234, A4235 or A4236), and a spring-powered lancet device (A4258);

(i) The following services are not covered as they are not medically necessary or medically appropriate:

(A) Peroxide (A4244), betadine, or phisoHex (A4246, A4247);

(B) Alternate site blood glucose monitors;

(D) Blood glucose test or reagent strips that use a visual reading and are not used in a glucose monitor;

(E) Disposable gloves;

(F) Home blood glucose disposable monitors;

(G) Jet injectors;

(H) Insulin delivery devices and related supplies other than those identified in this rule and OAR 410-122-0525;

(I) Reflectance colorimeter devices used for measuring blood glucose levels in clinical settings;

(J) Urine test or reagent strips or tablets.

(2) Guidelines:

(a) Insulin-treated means that the client is receiving insulin injections to treat their diabetes. Insulin does not exist in an oral form and therefore clients taking oral medication to treat their diabetes are not insulin-treated;

(b) A severe visual impairment is defined as a best corrected visual acuity of 20/200 or worse in both eyes;

(c) An order renewal is the act of obtaining an order for an additional period of time beyond that previously ordered by the treating practitioner;

(d) An order refill is the act of replenishing quantities of previously ordered items during the time period in which the current order is valid;

(e) A4256 describes control solutions containing high, normal, and low concentrations of glucose that can be applied to test strips to check the integrity of the test strips. This code does not describe the strip or chip which is included in a vial of test strips and which calibrates the glucose monitor to that particular vial of test strips;

(f) For glucose test strips (A4253), 1 unit of service = 50 strips. For lancets (A4259), 1 unit of service = 100 lancets.

(3) Documentation requirements:

(a) For supplies requiring prior authorization (PA), submit documentation that supports coverage criteria as specified in this rule are met;

(b) The order for home blood glucose monitors and/or diabetic testing supplies shall include all of the following:

(A) All item(s) to be dispensed;

(B) The specific frequency of testing;

(D) The date of the treating practitioner's signature;

(E) A start date of the order is only required if the start date is different than the signature date;

(d) For E2100 or E2101 in a client with impaired visual acuity, submit documentation that includes a narrative statement from the practitioner which indicates the client’s specific numerical visual acuity (e.g., 20/400) and that this result represents "best corrected" vision;

(e) For E2101 clients with impaired manual dexterity, submit documentation that includes a narrative statement from the practitioner which indicates an explanation of the client’s medical condition necessitating the monitor with special features;

(f) When requesting quantities of supplies that exceed utilization guidelines as specified in (1)(d)(B)(i)–(iv) (e.g., more than 100 blood glucose test strips per month for insulin-dependent diabetes mellitus), submit documentation supporting the medical appropriateness for the higher utilization as specified in (1)(d)(B)(v)(I)–(III) to the appropriate authorization authority for PA;

(g) Documentation that supports condition of coverage requirements for codes billed in this rule shall be kept on file by the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provider and made available to the Division on request;

(h) The appropriate diagnosis code describing the condition that necessitates glucose testing shall be included on each claim for the monitor, accessories, and supplies;

(i) Diabetic supply providers are not prohibited from creating data collection forms in order to gather medically appropriate information; however, the Division shall not rely solely on those forms to prove the medical appropriateness of services provided;

(j) A client’s medical records shall support the justification for supplies dispensed and billed to the Division.

(4) Billing and Payment Guidelines:

(a) Diabetic supplies shall be billed using a National Drug Code (NDC). DMEPOS provider types shall submit claims with appropriate NDC and HCPCS codes to the Division via the Web Portal or Point of Sale Systems via professional claim format. Pharmacy provider types shall submit claims with appropriate NDC to the Division via the Web Portal or Point of Sale Systems via pharmacy claim format. Claims submitted on these systems without NDC’s will not be processed. This NDC requirement applies to:

(A) Home glucose monitors; and

(B) Blood glucose test reagent strips;

(D) Insulin syringes;

(E) Spring powered lancet devices;

(F) Calibrating solutions and chips;

(b) For specialized glucose monitors and the respective testing supplies, such as those with special features for the visually impaired and those with manual dexterity problems, the provider shall obtain PA. After PA the provider can submit a professional claim to the Division;

(c) Orders received from prescribing clinicians for blood glucose test reagent strips that exceed utilization guidelines outlined in section (1)(d)(B)(i)–(iv) shall require PA from the Division. Diabetic supply providers may initially dispense up to utilization limits (i.e., 300 test strips, 300 lancets, and 500 insulin syringes) prior to obtaining PA for orders that exceed utilization guidelines. After PA is issued the remaining amount may be dispensed for a three-month time period.

(5) Procedure Codes: Table 122-0520 — Diabetic Supplies.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 18-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 82-2014, f. 12-23-14, cert. ef. 1-1-15
DMAP 42-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 12-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0525 External Insulin Infusion Pump

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover an external insulin infusion pump for the administration of continuous subcutaneous insulin for the treatment of diabetes mellitus when criterion (A) or (B) is met and criterion (C) or (D) is met:

(A) C-peptide testing requirement:

(i) The C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory’s measurement method; or

(ii) For a client with renal insufficiency and a creatinine clearance (actual or calculated from age, weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting C-peptide level is less than or equal to 200 percent of the lower limit of normal of the laboratory’s measurement method; and

(iii) A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 mg/dl.

(B) Beta cell autoantibody test is positive;

(i) Completed a comprehensive diabetes education program; and

(ii) Been on a program of multiple daily injections of insulin (i.e., at least three injections per day) with frequent self-adjustments of insulin dose for at least six (6) months prior to initiation of the insulin pump; and

(iii) Documented frequency of glucose self-testing an average of at least four (4) times per day during the two (2) months prior to initiation of the insulin pump and meets one (1) or more of the following criteria while on the multiple injection regimen:

(I) Glycosylated hemoglobin level (HbA1C) greater than seven (7) percent;

(II) History of recurring hypoglycemia;

(III) Wide fluctuations in blood glucose before mealtime;

(IV) Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL;

(V) History of severe glycemic excursions;

(D) The client has:

(i) Been on an external insulin infusion pump prior to enrollment in the medical assistance program, and;

(ii) Documented frequency of glucose self-testing an average of at least four times per day during the month prior to medical assistance program enrollment;

(b) For continued coverage of an external insulin pump and supplies, the client shall be seen and evaluated by the treating practitioner at least every three (3) months;

(c) The external insulin infusion pump shall be ordered and follow-up care rendered by a practitioner who manages multiple clients on continuous subcutaneous insulin infusion therapy and who works closely with a team including nurses, diabetic educators, and dieticians who are knowledgeable in the use of continuous subcutaneous insulin infusion therapy;

(d) The Division may cover supplies (including dressings) used with an external insulin infusion pump during the period of covered use of an infusion pump. These supplies are billed with codes A4224 or A4225;

(e) Code A4224 includes catheter insertion devices for use with external insulin infusion pump infusion cannulas and are not separately payable;

(f) A4224 is limited to one (1) unit of service per week.

(2) Coding guidelines:

(a) Code A4224 includes all cannulas, needles, dressings, and infusion supplies (excluding the insulin reservoir) related to continuous subcutaneous insulin infusion via external insulin infusion pump (E0784);

(b) Refer to the product classification list on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor website for appropriate Healthcare Common Procedure Coding System (HCPCS) codes;

(c) Insulin delivery devices and related supplies other than those identified in this rule and coverage table 122-0525 are not considered to be medically necessary or medically appropriate.

(3) Documentation requirements:

(a) With the request for PA, the DMEPOS provider shall submit medical justification that supports the criteria in this rule are met;

(b) When billing and dispensing for an item in Table 122-0525, the DMEPOS provider shall ensure that medical records corroborate all criteria in this rule are met;

(4) Table 122-0525.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 19-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0540 Ostomy Supplies

(1) Indications and Limitations of Coverage and Medical Appropriateness: The Division may cover ostomy supplies for a client with a surgically created opening (stoma) to divert urine or fecal contents outside the body:

(a) Only one liquid barrier may be dispensed at a time:

(A) A liquid or spray (A4369); or

(B) Individual wipes or swabs (A5120);

(b) For a client with a continent stoma, only one of the following means to prevent/manage drainage may be covered on a given day:

(A) Stoma cap (A5055);

(B) Stoma plug (A5081);

(D) Gauze pads (A6216);

(A) Bag (A4357); or

(B) Bottle (A5102);

(d) Provision of ostomy supplies for a client is limited to a three month supply;

(e) The following services are not covered:

(A) Ostomy clamps;

(B) Ostomy supplies when a client is in a covered home health episode;

(2) Documentation Requirements:

(a) For miscellaneous ostomy supplies (A4421),submit documentation which supports coverage criteria as specified in this rule are met to the responsible unit for prior authorization;

(b) Medical records which support conditions of coverage as specified in this rule are met must be kept on file by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request;

(c) A client’s medical records must support the justification for supplies billed to the Division including when a greater quantity of supplies than the amounts listed in this rule are dispensed (e.g., client has more than one ostomy).

(3) Table 122-0540-1, Maximum Quantity of Supplies — Monthly Basis.

(4) Table 122-0540-2, Maximum Quantity of Supplies — 6-Month Basis.

(5) Table 122-0540-3, Faceplate Systems.

(6) Table 122-0540-4, Procedure Codes.

[ED. NOTE: Tables referenced rule are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 20-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 63-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 17-2012, f. 3-30-12, cert. ef. 4-1-12
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0560 Urological and Bowel Supplies

(1) Indications and Limitations of Coverage and Medical Appropriateness:

(a) The Division may cover the following urinary catheters, external urinary collection devices, and medically appropriate related supplies when used to drain or collect urine for a client who has permanent urinary incontinence or permanent urinary retention;

(b) Indwelling Catheters (A4311–A4316, A4338–A4346):

(A) No more than one (1) catheter per month for routine catheter maintenance;

(B) Non-routine catheter changes when documentation substantiates medical appropriateness, such as for the following indications:

(i) Catheter is accidentally removed (e.g., pulled out by client);

(ii) Catheter malfunctions (e.g., balloon does not stay inflated, hole in catheter);

(iii) Catheter is obstructed by encrustation, mucous plug, or blood clot;

(iv) History of recurrent obstruction or urinary tract infection for which it has been established that an acute event is prevented by a scheduled change frequency of more than once (1) per month;

(C) A specialty indwelling catheter (A4340) or an all-silicone catheter (A4344, A4312, or A4315) when documentation in the client's medical record supports the medical appropriateness for that catheter rather than a straight Foley type catheter with coating (such as recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex);

(D) A three-way indwelling catheter either alone (A4346) or with other components (A4313 or A4316) only if continuous catheter irrigation is medically appropriate;

(A) Only one (1) insertion tray per episode of indwelling catheter insertion;

(B) One (1) intermittent catheter with insertion supplies (A4353) per episode of medically appropriate sterile intermittent catheterization;

(d) Urinary Drainage Collection System (A4314-A4316, A4354, A4357, A4358, A5102, and A5112):

(A) For routine changes of the urinary drainage collection system as noted in Table 122-0560-1;

(B) Additional charges for medically appropriate non-routine changes when the documentation substantiates the medical appropriateness (e.g., obstruction, sludging, clotting of blood, or chronic, recurrent urinary tract infection);

(C) A vinyl leg bag (A4358) or a latex leg bag (A5112) only for clients who are ambulatory or are chair or wheelchair bound;

(e) Intermittent Irrigation of Indwelling Catheters:

(A) Supplies for the intermittent irrigation of an indwelling catheter when they are used on an as needed (non-routine) basis in the presence of acute obstruction of the catheter;

(B) Routine intermittent irrigations of a catheter are not covered;

(D) Covered supplies for medically appropriate non-routine irrigation of a catheter include either an irrigation tray (A4320) or an irrigation syringe (A4322), and sterile water/saline (A4217);

(f) Continuous Irrigation of Indwelling Catheters:

(A) Supplies for continuous irrigation of a catheter when there is a history of obstruction of the catheter and the patency of the catheter cannot be maintained by intermittent irrigation in conjunction with medically appropriate catheter changes;

(B) Continuous irrigation as a primary preventative measure (i.e., no history of obstruction) is not covered;

(C) Documentation must substantiate the medical appropriateness of catheter irrigation and in particular continuous irrigation as opposed to intermittent irrigation;

(D) The records must also indicate the rate of solution administration and the duration of need;

(E) Covered supplies for medically appropriate continuous bladder irrigation include a three-way Foley catheter (A4313, A4316, and A4346), irrigation tubing set (A4355), and sterile water/saline (A4217):

(i) The Division may cover one (1) irrigation tubing set per day for continuous catheter irrigation;

(ii) Continuous irrigation is considered a temporary measure and may only be covered for up to 14 days;

(g) Intermittent Catheterization: Intermittent catheter supplies when basic coverage criteria are met and the client or caregiver can perform the procedure:

(A) For each episode of covered catheterization, one (1) catheter (A4351, A4352) and an individual packet of lubricant (A4332); or

(B) One (1) sterile intermittent catheter kit (A4353) when the client requires catheterization and meets one of the following criteria (i-iv):

(i) The client is immunosuppressed. Examples of immunosuppressed clients include (but are not limited) clients who are:

(I) On a regimen of immunosuppressive drugs post-transplant;

(II) On cancer chemotherapy;

(III) Has AIDS;

(IV) Has a drug-induced state such as chronic oral corticosteroid use;

(ii) The client has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization;

(iii) The client is a pregnant, spinal cord-injured female with neurogenic bladder (for duration of pregnancy only);

(iv) The client has had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351/A4352 and sterile lubricant (A4332), twice within the 12-month period prior to the initiation of sterile intermittent catheter kits. A urinary tract infection means a urine culture with greater than 10,000 colony forming units of a urinary pathogen; and documentation in the client’s medical records of concurrent presence of one or more of the following signs, symptoms or laboratory findings:

(I) Fever (oral temperature greater than 38º C [100.4º F]);

(II) Systemic leukocytosis;

(III) Change in urinary urgency, frequency, or incontinence;

(IV) Appearance of new or increase in autonomic dysreflexia (sweating, bradycardia, blood pressure elevation);

(V) Physical signs of prostatitis, epididymitis, orchitis;

(VI) Increased muscle spasms;

(VII) Pyuria (greater than five white blood cells [WBCs] per high-powered field);

(C) The kit code (A4353) must be used for billing even if the components are packaged separately rather than together as a kit;

(h) Coude (Curved) Tip Catheters:

(A) Use of a Coude (curved) tip catheter (A4352) in female clients is rarely medically appropriate;

(B) For any client, when a Coude tip catheter is dispensed and billed, there must be specific documentation in the client's medical record why a Coude tip catheter is required rather than a straight tip catheter;

(i) External Catheters/Urinary Collection Devices:

(A) Male external catheters (condom-type) or female external urinary collection devices for clients who have permanent urinary incontinence when used as an alternative to an indwelling catheter;

(B) Coverage for male external catheters (A4349) is limited to 35 per month;

(D) Male external catheters (condom-type) or female external urinary collection devices are not covered for clients who also use an indwelling catheter;

(E) The Division may cover specialty type male external catheters such as those that inflate or that include a faceplate (A4326) or extended wear catheter systems (A4348) only when documentation substantiates the medical appropriateness for such a catheter;

(F) Coverage of female external urinary collection devices is limited to one metal cup (A4327) per week or one (1) pouch (A4328) per day;

(j) Anal Irrigation System and Catheter:

(A) Refer to the Prioritized List of Health Services Anal Irrigation Systems Guideline Note for coverage guidelines;

(B) Utilization and frequency are determined by the treating practitioner. The following represents the usual maximum number of kits and catheters expected to be medically appropriate:

(i) A4459 – 1 unit (one unit = one kit) every threee (3) months;

(ii) A4453 – 31 units (one unit = one catheter) per month;

(k) Miscellaneous Supplies:

(A) Appliance cleaner (A5131): One (1) unit of service (16 oz) per month when used to clean the inside of certain urinary collecting appliances (A5102, A5105, A5112);

(B) One (1) external urethral clamp or compression device (A4356) every three (3) months or sooner if the rubber/foam casing deteriorates;

(C) Adhesive catheter anchoring devices (A4333, three per week) and catheter leg straps (A4334, one (1) per month) for indwelling urethral catheters;

(D) A catheter/tube anchoring device (A5200) separately payable when it is used to anchor a covered suprapubic tube or nephrostomy tube;

(E) Non-Sterile Gloves (A4927): four (4) units are allowed per month, one (1) unit = 100 each (50 pairs);

(l) The following services are not covered:

(A) Creams, salves, lotions, barriers (liquid, spray, wipes, powder, paste) or other skin care products (A6250);

(B) Catheter care kits (A9270);

(D) Catheter clamp or plug (A9270);

(E) Disposable underpads, all sizes, diapers or incontinence garments, any type, disposable or reusable unless authorized under 410-122-0630 Incontinent Supplies;

(F) Drainage bag holder or stand (A9270);

(G) Urinary suspensory without leg bag (A4359);

(H) Measuring container (A9270);

(I) Urinary drainage tray (A9270);

(J) Gauze pads (A6216–A6218) and other dressings;

(K) Other incontinence products not directly related to the use of a covered urinary catheter or external urinary collection device (A9270);

(L) Irrigation supplies that are used for care of the skin or perineum of incontinent clients;

(M) Syringes, trays, sterile saline, or water used for routine irrigation;

(N) Disposable external urethral clamp or compression device, with pad and/or pouch, each.

(2) Guidelines:

(a) Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected within three (3) months. A determination that there is no possibility that the client's condition may improve sometime in the future is not required. If the medical records, including the judgment of the attending treating practitioner, indicate the condition is of long and indefinite duration (ordinarily at least three (3) months), the test of permanence is considered met;

(b) A urinary intermittent catheter with insertion supplies (A4353) is a kit, which includes a catheter, lubricant, gloves, antiseptic solution, applicators, drape, and a tray or bag in a sterile package intended for single use;

(c) Adhesive strips or tape used with male external catheters are included in the allowance for the code and are not separately payable;

(d) Catheter insertion trays (A4310–A4316, A4353, and A4354) that contain component parts of the urinary collection system, (e.g., drainage bags and tubing) are inclusive sets and payment for additional component parts may be allowed only per the stated criteria in each section of the policy;

(e) Extension tubing (A4331) may be covered for use with a latex urinary leg bag (A5112) and is included in the allowance for codes A4314, A4315, A4316, A4354, A4357, A4358, and A5105 and A4331 cannot be separately billed with these codes;

(f) Use A4333 when used to anchor an indwelling urethral catheter;

(g) Use code A5105 when billing for a urinary suspensory with leg bag;

(h) Replacement leg straps (A5113, A5114) are used with a urinary leg bag (A4358, A5105, or A5112). These codes are not used for a leg strap for an indwelling catheter;

(i) A4326 is a male external catheter with an integrated collection chamber that does not require the use of an additional leg bag.

(3) Documentation Requirements:

(a) For services requiring prior authorization (PA), submit documentation which supports coverage criteria as specified in this rule are met;

(b) Intermittent Catheterization:

(A) The practitioner’s order must indicate the actual number of times intermittent catheterization is performed per day;

(B) The client’s medical records must support the number of times per day intermittent catheterization is performed;

(c) When requesting quantities of supplies greater than the maximum units specified in this rule, submit documentation supporting the medical appropriateness for the higher utilization to the appropriate authorization authority for PA;

(d) Documentation, which supports condition of coverage requirements for codes billed in this rule, must be kept on file by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request;

(e) A client’s medical records must support the justification for supplies billed to the Division.

(4) Table 122-0560-1, Maximum Quantity of Supplies.

(5) Table 122-0560-2.

(6) Table 122-0560-3, Procedure Codes.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 21-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 64-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0580 Bath Supplies

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover bath supplies when the client meets the conditions of coverage in OAR 410-122-0080 and when the following guidelines are met:

(a) A rehab shower/commode chair may be covered when all of the following criteria are met:

(A) Client is unable to use a standard shower chair/bench due to a neurological or musculoskeletal condition;

(B) Client has positioning, trunk stability or neck support needs that a standard shower chair/bench cannot provide;

(D) Less costly alternatives have been considered or tried and ruled out;

(E) The rehab shower/commode chair meets the following specifications and standard features as a minimum:

(i) Constructed specifically for use as a rehab shower/commode chair (corrosive resistant);

(ii) Swing-away or detachable arms;

(iii) Removable commode pan holder and pan;

(iv) Adjustable removable footrests;

(v) Wheel lock system;

(F) The rehab shower/commode chair must be supplied by a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the rehab shower/commode chair selection for the client;

(G) Verification of the healthcare common procedure coding system (HCPCS) code assignment by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor is not required for a rehab shower/commode chair;

(H) Use E1399 for a rehab shower/commode chair and accessories that are not included in the base for the rehab shower/commode chair. PDAC coding verification is not required for these items as they are statutorily excluded from coverage by Medicare and have no assigned HCPCS codes.

(b) Custom/Specialized Pediatric Bath Chair:

(A) Custom/Specialized pediatric bath chair requires fitting and/or adjustment to treat a specific medical need;

(B) Custom/Specialized pediatric bath chairs require prior authorization (PA). Documentation must include the following:

(i) The treating practitioner’s records supporting the medical appropriateness of the item ordered and explaining why a standard bath chair will not meet the individual’s medical needs; and

(ii) Documentation shall identify less costly alternatives and explain why a less costly alternative will fail to meet the individual’s medical needs.

(C) A custom/specialized pediatric bath chair shall be billed using the appropriate HCPCS code (E0240, E0245, or E0247) and modifier 22;

(i) DMEPOS providers shall refer to the product classification list on the PDAC contractor website for coding verification;

(ii) A pediatric custom/specialized bath chair billed using HCPCS code E0240, E0245, or E0247 and modifier 22 shall be reimbursed following the payment methodology outlined in OAR 410-122-0186 for manually priced items.

(2) Documentation requirements:

(a) The practitioner’s order and medical justification for the equipment must be kept on file by the DMEPOS provider. The client’s medical records must contain information which supports the medical appropriateness of the item and accessories ordered;

(b) For services requiring prior authorization, submit documentation which supports conditions of coverage in this rule are met.

(3) Table 122-0580 Bath Supplies.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 22-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0590 Patient Lifts

(1) Indications and coverage — A lift is covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the client would be bed confined.

(2) The areas within the client’s residence where the lift will be utilized must be able to accommodate and allow for the effective use of the lift. The Division does not reimburse for adapting the living quarters.

(3) A sling or seat for a client lift may be covered as an accessory when ordered as a replacement for the original equipment item.

(4) E0621 is included in the allowance for E0630 when provided at the same time.

(5) E0635 may be covered only when a client weighs 450 pounds or more;

(6) Procedure codes:

(a) E0621 — Sling or seat, client lift, canvas or nylon — Purchase — Prior authorization (PA) required;

(b) E0630 — Client lift, hydraulic with seat or sling (considered purchased after 10 months of rental) — Purchase, rent or repair — PA required;

(c) E0635 — Client lift, electric, with seat or sling — Rent only. This item is a capped rental and becomes the property of the client after 10 months of continuous rental or when the usual purchase price is reached, whichever is lesser. May be covered for a nursing facility client — PA required.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 69-2023, minor correction filed 08/19/2023, effective 08/19/2023
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01

Or. Admin. R. 410-122-0600 Toilet Supplies

(1) The Division may consider coverage for commodes when:

(a) The client is physically incapable of utilizing regular toilet facilities. This would occur when the client is confined to:

(A) A single room; or

(B) One level of the home environment and there is no toilet on that level; or

(b) Extra-wide/heavy-duty commodes may be covered when a client weighs 300 pounds or more and meets the conditions of coverage for commodes;

(c) Only bariatric commodes coded as E1399 (durable medical equipment, miscellaneous) may be covered for a client residing in a nursing facility, subject to service limitations of Division rules, when all of the following requirements are met:

(A) The client meets the conditions of coverage as specified in this rule; and

(B) The bariatric commode has been assigned code E1399 by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor.

(d) A commode with detachable arms (E0165) may be covered if the detachable arms feature is necessary to facilitate transferring the client or if the client has a body configuration that requires extra width.

(e) A commode with integrated seat lift mechanism (E0170, E0171) is covered if it is medically appropriate and client meets criteria for a seat lift mechanism. A commode with seat lift mechanism is intended to allow the client to walk after standing.(f) Toilet seat lift mechanisms (E0172) and footrests (E0175) are not primarily medical in nature.

(2) Documentation requirements:

(a) Documentation must include the practitioner’s order, the client’s height and weight and information supporting the medical appropriateness for the commode dispensed;

(b) For codes requiring prior authorization (PA), submit documentation which supports conditions of coverage are met as specified in this rule.

(3) Procedure Codes: Table 122-0600 Toilet Supplies.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 23-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
HR 17-1996, f. & cert. ef. 8-1-96
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0620 Miscellaneous Supplies

Procedure Codes — Table 122-0620.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 32-1999, f. & cert. ef. 10-1-99
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0625 Surgical Dressing

Procedure Codes: Table 122-0625 Surgical Dressing.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 17-2026, minor correction filed 05/18/2026, effective 05/18/2026
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0630 Incontinent Supplies

(1) The Division may cover incontinent supplies for urinary or fecal incontinence in accordance with Prioritized List of Health Services Fecal Incontinence Guideline Note and as follows:

(a) Category I Incontinent Supplies: For up to 200 units (any code or product combination in this category) per month, unless documentation supports the medical appropriateness for a higher quantity. For quantities over this limit a prior authorization shall be required. When requesting multiple Category I product types (i.e., diapers and liners) that exceed the allowable, prior authorization and documentation as described in (4)(a)(D) of this rule are required;

(b) Category II Underpads:

(A) Disposable underpads: For up to 100 units (any combination of T4541 and T4542) per month, unless documentation supports the medical appropriateness for a higher quantity, up to a maximum of 150 units per month;

(B) Reusable/washable underpads: For up to eight units (any combination of T4537 and T4540) in a 12-month period;

(C) Category II Underpads may be separately payable with Category I Incontinent Supplies with documentation that supports medical appropriateness for the use of this product;

(D) T4541 and T4542 are not separately payable with T4537 and T4540 for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for eight reusable/washable underpads on a given date of service, a client would not be eligible for disposable underpads for the subsequent 12 months;

(A) For up to 12 units in a 12 month period;

(B) Category III Washable Protective Underwear is not separately payable with Category I Incontinent Supplies for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for 12 units of T4536 on a given date of service, a client would not be eligible for Category I Incontinent Supplies for the subsequent 12 months;

(d) The following services require PA:

(A) A4335 (Incontinence supply; miscellaneous);

(B) T4543 (Disposable incontinence product, brief/diaper, bariatric);

(D) Quantity of supplies greater than the amounts listed in this rule as the maximum monthly utilization (e.g., more than 200 units per month of Category I Incontinent Supplies, or two (2) units per month of gloves).

(2) Incontinent supplies are not covered:

(a) For nocturnal enuresis; or

(b) For children under the age of three (3).

(3) A provider may only submit A4335 when there is no definitive Healthcare Common Procedure Coding System (HCPCS) code that meets the product description.

(4) Documentation requirements:

(a) The client’s medical records shall support the medical appropriateness for the services provided or being requested by the medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider, including, but not limited to:

(A) For all categories, the medical reason and condition causing the incontinence; and

(B) When a client is using urological or ostomy supplies at the same time as incontinent products specified in this rule, information that clearly corroborates the overall quantity of supplies needed to meet bladder and bowel management is medically appropriate;

(C) For all clients not residing in their home subsequent PA requests for incontinence product(s), the provider shall submit a log with the PA request. This log shall be the most recent log for the client documenting the number and frequency of incontinent product changes;

(D) PA requests for multiple Category I incontinence product types for the same client (i.e. doubling up) shall be accompanied by adequate explanation from the client’s ordering practitioner to explain why a single, more appropriate, incontinence product cannot be used;

(E) Although PA is not required for Category II incontinence products, the DMEPOS provider shall have documentation on file from the prescribing practitioner supporting medical appropriateness;

(F) When requesting PA for T4543 (Bariatric Brief/Diaper) or T4544 (Protective underwear/pull-on), submit product information showing that the item is size XXL or larger. The request shall also include client weight and measurements that support the use of the bariatric incontinence product (e.g., client weight, waist and hip size). These items are manually priced following payment methodology outlined in OAR 410-122-0186.

(b) For services requiring PA, submit documentation as specified in (4)(a)(A)–(E) and (F);

(c) The DMEPOS provider is required to keep supporting documentation on file and make available to the Division on request.

(5) Quantity specification:

(a) For PA and reimbursement purposes, a unit count for Category I–III codes is considered as a single or individual piece of an item and not as a multiple quantity;

(b) If an item quantity is listed as number of boxes, cases or cartons, the total number of individual pieces of that item contained within that respective measurement (box, case or carton) shall be specified in the unit column on the PA request. See table 122-0630-2;

(6) Table 122-0630-1, Incontinent Supplies

(7) Table 122-0630-2, Incontinent Supplies — Counting Units and Pieces

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 24-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 65-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 62-2015, f. 10-29-15, cert. ef. 11-1-15
DMAP 17-2012, f. 3-30-12, cert. ef. 4-1-12
DMAP 42-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 76-2003, f. & cert. ef. 10-1-03
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 64-2001, f. 12-28-01, cert. ef. 1-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0640 Eye Prostheses

(1) Indications and coverage:

(a) An eye prosthesis is indicated for a client (adult or child) with absence or shrinkage of an eye due to birth defect, trauma, or surgical removal;

(b) For clients under age 21, the prescribing practitioner shall determine and document medical appropriateness of the eye prosthesis and related services;

(A) Polishing and resurfacing will be allowed on a twice per year basis;

(B) Replacement is covered every five years if documentation supports medical appropriateness. An exception to this limitation is allowed when clinical documentation supports medical appropriateness for more frequent replacement;

(C) One enlargement (V2625) or reduction (V2626) of the prosthesis is covered. Additional enlargements or reductions are rarely medically indicated and are therefore covered only when clinical documentation supports medical appropriateness.

(2) Documentation requirements:

(a) An order for each item shall be signed and dated by the treating physician, kept on file by the supplier, and made available upon request;

(b) Documentation of medical appropriateness that has been reviewed and signed by the prescribing practitioner shall be kept on file by the supplier and made available upon request;

(c) When billing for an item or service at a greater frequency than allowed, there shall be documentation in the patient’s medical records that corroborates the order and supports the medical appropriateness of the items. This documentation shall be kept on file by the supplier and available upon request.

(3) Procedure Codes – Table 122-0640.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 25-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 60-2014, f. 10-3-14, cert. ef. 10-7-14
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
HR 17-1996, f. & cert. ef. 8-1-96
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0655 External Breast Prostheses

(1) Indications and Limitations of Coverage and Medical Appropriateness:

(a) The Division may cover an external breast prosthesis for a client who has had a mastectomy;

(b) An external breast prosthesis garment, with mastectomy form (L8015) may be covered for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis;

(c) An external breast prosthesis of a different type may be covered if there is a change in the client’s medical condition necessitating a different type of item;

(d) The Division will pay for only one breast prosthesis per side for the useful lifetime of the prosthesis;

(e) The Division will pay for a breast prosthesis for a client residing in a nursing facility;

(f) Two prostheses, one per side, are allowed for a client who has had bilateral mastectomies;

(g) More than one external breast prosthesis per side is not covered;

(h) An external breast prosthesis of the same type may be replaced if it is lost or is irreparably damaged (this does not include ordinary wear and tear);

(i) Replacement sooner than the useful lifetime because of ordinary wear and tear is not covered.

(2) Guidelines:

(a) Use code A4280 when billing for an adhesive skin support that attaches an external breast prosthesis directly to the chest wall;

(b) L8000 is limited to a maximum of four units every 12 months;

(d) The right (RT) and left (LT) modifiers must be used with these codes. When the same code for two breast prostheses are billed for both breasts on the same date, the items (RT and LT) must be entered on the same line of the claim form using the RTLT modifier and two units of service;

(e) The useful lifetime expectancy for silicone breast prostheses is two years;

(f) For fabric, foam, or fiber filled breast prostheses, the useful lifetime expectancy is six months.

(3) Requirements:

(a) For services that do not require prior authorization (PA), the durable medical equipment, prosthetic, orthotic and supplies (DMEPOS) provider must have documentation on file which supports conditions of coverage as specified in this rule are met;

(b) For services that require PA, the DMEPOS provider must submit documentation for review which supports conditions of coverage as specified in this rule are met;

(4) Table 122-0655 (Procedure Codes): The procedure codes in this table may be covered for purchase.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09
Renumbered from 410-122-0255, DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0658 Gradient Compression Stockings/Sleeves

(1) Indications and Limitations of Coverage and Medical Appropriateness:

(a) The Division may cover gradient compression stockings/sleeves for the following indications when the client meets the conditions of coverage in OAR 410-122-0080 and when all the following guidelines and criteria are met:

(A) Ulceration due to chronic venous insufficiency;

(B) Varicose veins with ulcer or inflammation;

(D) Deep vein thrombosis (DVT) prophylaxis during pregnancy and postpartum or immobilization due to surgery, trauma, or debilitation;

(E) Funded lymphedema conditions even in the absence of ulcers or other complications; and

(F) Edema following a covered surgery, fracture, burns, or other trauma;

(b) A gradient compression stocking may be covered when it is used to secure a primary dressing over an open venous stasis ulcer that is currently being treated by a practitioner and requires medically necessary debridement and when the gradient stocking delivers compression less than 50 mmHg;

(c) Two (2) gradient compression stockings/sleeves per affected limb may be provided at dispensing (the second one is for use while the first one is being laundered);

(d) Replacement stockings/sleeves are limited to two (2) per affected limb every six (6) months. Requests for quantities that exceed this amount require detailed medical documentation (e.g., change in size, unusual drainage, wear that renders them ineffective);

(e) Custom-made gradient compression stockings/sleeves require prior authorization with documentation that supports that the treating practitioner has considered ready-made gradient compression stockings/sleeves and the reason why they will not meet the medical needs of the client.

(f) The following services are not covered:

(A) Antiembolism stockings (A4490-A4510);

(B) Garter belts (A6544);

(i) Solely for the purpose of air travel;

(ii) Treatment of non-funded lymphedema conditions;

(iii) Venous insufficiency without stasis ulcers;

(D) Support hose (pantyhose).

(2) Gradient compression garments, related supplies and accessories are covered for the treatment of lymphedema and in accordance with the Prioritized List of Health Services Lymphedema Guideline Note.

(a) A quantity of three (3) daytime garments or wraps per body area are allowed once every six (6) months;

(b) A quantity of two (2) nighttime garments per body area are allowed once every two (2) years;

(c) Replacements needed in cases of loss, theft, or irreparable damage may be covered by the Division in accordance with OAR 410-122-0184;

(d) Lymphedema compression treatment items include the following:

(A) Standard and custom daytime gradient compression garments;

(B) Nighttime gradient compression garments;

(D) Compression bandaging systems;

(E) Accessories such as zippers, liners/linings, padding or fillers that are necessary for the effective use of a gradient compression garment or wrap;

(F) Refer to Table 122-0658 for a complete list of HCPCS codes;

(G) DMEPOS providers shall refer to the product classification list on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor website for coding verification and HCPCS codes used to identify specific durable medical equipment, prosthetics, orthotics and supplies (DMEPOS).

(3) Documentation Requirements: Medical records that support the conditions of coverage are met, as specified in this rule, shall be kept on file by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request.

(4) Table 122-0658

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 26-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 66-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 59-2015, f. 10-28-15, cert. ef. 11-1-15
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08

Or. Admin. R. 410-122-0660 Orthotics and Prosthetics

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover some orthotics and prosthetics for covered conditions;

(b) Use the current Healthcare Common Procedure Coding System (HCPCS) Level II Guide for current codes and descriptions;

(d) For clients under age 21, the prescribing practitioner shall determine and document medical appropriateness;

(e) The hospital is responsible for reimbursing the provider for orthotics and prosthetics provided on an inpatient basis;

(f) Evaluations, office visits, fittings, and materials are included in the service provided;

(g) Evaluations will only be reimbursed as a separate service when the provider travels to a client’s residence to evaluate the client’s need;

(h) See Division 129, Speech-Language Pathology, Audiology and Hearing Aid Services for coverage criteria for speech and audiology prosthetic devices and accessories.

(i) See OAR 410-122-0658 for coverage criteria for mastectomy sleeves (L8010).

(2) Documentation requirements:

(a) For services that require prior authorization (PA): Submit documentation for review that supports conditions of coverage as specified in this rule are met;

(b) For services that do not require PA: Medical records that support conditions of coverage as specified in this rule are met shall be on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request.

(3) Table 122-0660-1: Codes requiring PA.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 27-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 60-2015, f. 10-29-15, cert. ef. 11-1-15
DMAP 17-2012, f. 3-30-12, cert. ef. 4-1-12
DMAP 40-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91

Or. Admin. R. 410-122-0662 Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover some ankle-foot orthotics (AFOs) and knee-ankle-foot Orthotics (KAFOs) and related services for a covered condition, for this episode, when the covered device has not been billed to the Division with a Current Procedure Terminology (CPT) code, Healthcare Common Procedure Coding System (HCPCS) code or diagnosis code by any other healthcare provider, and in addition specifically for:

(a) AFOs not used during ambulation: A static AFO (L4396) may be covered when (A)-(E) are met:

(A) The client has a plantar flexion contracture of the ankle (Internal Classification of Diseases (ICD)-10 diagnosis code M24.571, M24.572) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture);

(B) There is a reasonable expectation of the ability to correct the contracture;

(D) The static AFO is used as a component of a therapy program that includes active stretching of the involved muscles and/or tendons;

(E) The pre-treatment passive range of motion is measured with a goniometer and an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home) is documented in the client’s treatment plan;

(b) AFOs and KAFOs used during ambulation:

(A) AFOs described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360 and L4386 with weakness or deformity of the foot and ankle requiring stabilization fro medical reasons and with potential to benefit functionally;

(B) KAFOs described by codes L2000-L2038, L2126-L2136 and L4370 when conditions of coverage are met for an AFO and additional knee stability is required:

(C) AFOs and KAFOs that are molded-to-patient model, or custom-fabricated when basic coverage criteria for an AFO or KAFO are met and one of the following criteria is met:

(i) The client could not be fit with a prefabricated AFO;

(ii) The condition necessitating the orthotic is expected to be permanent or of longstanding duration (more than six months);

(iii) There is a need to control the knee, ankle or foot in more than one plane;

(iv) The client has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury;

(v) The client has a healing fracture that lacks normal anatomical integrity or anthropometric proportions;

(d) Evaluation of the client, measurement and/or casting and fitting of the orthotic are included in the allowance for the orthotic;

(e) Repairs/Replacement:

(A) Repairs to a covered orthotic due to wear or to accidental damage when necessary to make the orthotic functional. If the expense for repairs exceeds the estimated expense of providing another entire orthot, no payment will be made for the amount in excess;

(B) Replacement of a complete orthotic or component of an orthotic due to loss, significant change in the client’s condition or irreparable accidental damage if the device is still medically appropriate and conditions of coverage are met;

(i) May only bill for the actual time involved in the repair of an orthotic;

(ii) May not use this code for any labor involved in the evaluation, fabrication or fitting of a new or full replacement orthotic;

(iii) Use for the labor component of repair of a previously provided orthotic;

(D) Labor Allowance:

(i) Included in the replacement of an orthotic component coded with a specific L code;

(ii) Not included in the replacement of an orthotic component coded with L4210;

(E) Replacement items with specific HCPCS codes:

(i) Use L4392 and L4394 for replacement soft interfaces used with ankle contracture orthotics or foot drop splints;

(ii) Use L2999 (Lower extremity orthotics, not otherwise specified) for replacement components that do not have a specific HCPCS code;

(iii) Addition codes L4002 — L4130, L4392 for replacement components are not payable at initial issue of a base orthotic;

(f) The codes specified in this rule may be covered for a client residing in a nursing facility;

(g) Quantities of supplies greater than those described in the policy as the usual maximum amounts only when supported by documentation clearly and maximum amounts only when supported by documentation clearly and specifically explaining the medical appropriateness of the excess quantities.

(2) Exclusions: The following services are not covered;

(a) A static AFO and replacement interface for:

(A) A fixed contracture; or

(B) A foot drop without an ankle flexion contracture;

(b) A component of a static AFO that is used to address positioning of the knee or hip;

(c) A foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394) for a non-ambulatory client when used solely for the prevention or treatment of a pressure ulcer;

(d) An AFO or KAFO and any related addition for an ambulatory client when used solely for treatment of edema and/or prevention or treatment of a pressure ulcer;

(e) Walking boots used primarily to relieve pressure, especially on the sole of the foot or used solely for the prevention or treatment of a pressure ulcer;

(f) Elastic support garments (L1901);

(g) Socks (L2840, L2850) used in conjunction with orthotics;

(h) Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out;

(i) A foot pressure off-loading/supportive device (A9283);

(j) L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) if either the coverage criteria for the base orthotic is not met or the specific addition is not medically appropriate.

(3) Coding Guidelines:

(a) A prefabricated orthotic is one that is manufactured in quantity without a specific client in mind. A prefabricated orthotic may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific client (i.e., custom fitted). An orthotic that is assembled from prefabricated components is considered prefabricated. Any orthotic that does not meet the definition of a custom-fabricated orthotic is considered prefabricated;

(b) A custom-fabricated orthotic is individually made for a specific client starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as cutting, bending, molding, sewing, etc. It may involve some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item;

(c) A molded-to-patient model orthotic is a particular type of custom-fabricated orthotic in that an impression of the specific body part is made (by means of a plaster cast, computer-aided design and computer-aided manufacturing (CAD-CAM) technology, etc.). This impression is used to make a positive model (of plaster or other material) of the body part. The orthotic is then molded on this positive model;

(d) Ankle-foot orthotics extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. These features distinguish them from foot orthotics that are shoe inserts that do not extend above the ankle. A nonambulatory ankle-foot orthotic may be either an ankle contracture splint, night splint or a foot drop splint;

(e) A static AFO (L4396) is a prefabricated ankle-foot orthotic that has all of the following characteristics:

(A) Designed to accommodate an ankle with a plantar flexion contracture up to 45°;

(B) Applies a dorsiflexion force to the ankle;

(D) Has a soft interface;

(f) A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthotic that has all of the following characteristics:

(A) Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg);

(B) Not designed to accommodate an ankle with a plantar flexion contracture;

(D) Has a soft interface.

(4) HCPCS Modifiers:

(a) EY — No physician or other licensed health care provider order for this item or service;

(b) GY — Item or service statutorily excluded or does not meet the definition of any Medicare benefit:

(A) If an AFO or a KAFO is used solely for the treatment of edema and/or for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and any related additional code;

(B) If a walking boot (L4360, L4386), static AFO (L4396) or foot drop splint/recumbent positioning device (L4398) is used solely for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and to the code for the replacement liner (L4392, L4394);

(C) When the GY modifier is added to a code there must be a short narrative statement indicating why the GY modifier was used — e.g., “used to prevent pressure ulcer” or “used to treat pressure ulcer” or “used to treat edema”. This statement must be entered in the narrative field of an electronic claim or attached to a hard copy claim;

(c) KX — Requirements specified in the medical policy have been met. The provider must add a KX modifier to the AFO/KAFO base and additional codes only if all the coverage criteria of this policy have been met and evidence of such is retained in the provider’s files;

(d) LT — Left Side; RT — Right Side:

(A) The right (RT) and left (LT) modifiers must be used with orthotic base codes, additions and replacement parts;

(B) When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using the LTRT modifiers and 2 units of service.

(5) Documentation Requirements:

(a) L2999 is the only code in this rule that requires prior authorization (PA): For a PA request, submit documentation for review that supports conditions of coverage as specified in this rule are met, including the plan of care, if applicable;

(b) For services that do not require PA: Documentation from the medical record that supports conditions of coverage as specified in this rule are met must be kept on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider;

(c) Prior to billing for each new or full replacement item, the DMEPOS provider must first have received a completed written, signed and dated practitioner’s order that includes:

(A) The treating diagnosis code that justifies the need for the orthotic device;

(B) Detailed description of the item including all options or additional features;

(d) For custom-fabricated orthotics, documentation must support the medical appropriateness of that type device rather than a prefabricated orthotic;

(e) For L2999:

(A) The request for PA must include the following information:

(i) A narrative description of the item (for custom fabricated items); or

(ii) The manufacturer’s name and model name/number (for pre-fabricated items); and

(iii) Justification of medical appropriateness for the item;

(iv) For replacement components, a HCPCS code or the manufacturer’s name and model name/number of the base orthotic;

(v) The manufacturer’s name and model name/number must be entered in the narrative field of an electronic claim;

(f) Repair of orthotic devices:

(A) A practitioner’s order is not required;

(B) A detailed description of the reason for the repair, part that is being repaired or replaced must be on file with the DMEPOS provider;

(i) L4210 must include a description of each item that is billed;

(ii) L4205 must include an explanation of what is being repaired;

(D) All codes for repairs of orthotics billed with the same date of service must be submitted on the same claim;

(g) The provider must include the ICD-10 diagnosis code for the underlying condition on the claim for a static AFO (L4396) or replacement interface material (L4392);

(h) All codes for orthotics billed with the same date of service must be submitted on the same claim;

(i) When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, there must be documentation in the client’s medical record supporting the medical appropriateness for the higher utilization;

(j) The client’s medical record must support the medical appropriateness for items and all additions billed to the Division and this documentation must be made available to the Division on request.

(6) Table 122-0662

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 28-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 40-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08

Or. Admin. R. 410-122-0678 Dynamic Adjustable Extension/Flexion Device

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover some dynamic adjustable extension/flexion devices for a covered condition when all of the following conditions are met:

(a) As an adjunct to physical therapy for clients with signs and symptoms of persistent joint stiffness in the sub-acute injury or post-operative period (> 3 weeks but < 4 months after injury or surgical procedure) when the device is applied and managed under the direct supervision of a physical therapist;

(b) As an adjunct to physical therapy in the acute post-operative period for clients who are undergoing additional surgery to improve the range of motion of a previously affected joint when the device is managed under the direct supervision of a physical therapist;

(c) For this episode, the device has not been billed to the Division with a current procedure terminology (CPT) code, healthcare common procedure coding system (HCPCS) code, or diagnosis code by any other healthcare provider;

(d) Reimbursement is limited to a maximum of four (4) months per episode;

(e) Reimbursement is on a month-to-month rental basis only.

(2) Documentation requirements:

(a) Submit medical records that support the conditions of coverage, as specified in this rule, have been met, including the treatment plan from the physical therapist;

(b) The treatment plan shall include:

(A) Baseline measurements (pre-intervention measurements) of range of motion (ROM) limitations;

(B) Weekly ROM measurements with documented 10 degree improvement.

(3) Refer to Table 122-0678 — Dynamic Adjustable Extension/Flexion Devices for HCPCS codes.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-122-0680 Facial Prostheses

(1) Indications and Coverage:

(a) Covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect;

(b) Adhesives, adhesive remover and tape used in conjunction with a facial prosthesis are covered. Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered;

(A) Evaluation of the client;

(B) Pre-operative planning;

(D) Labor involved in the fabrication and fitting of the prosthesis;

(E) Modifications to the prosthesis made at the time of delivery of the prosthesis or within 90 days thereafter;

(F) Repair due to normal wear or tear within 90 days of delivery;

(G) Follow-up visits within 90 days of delivery of the prosthesis;

(d) Modifications to a prosthesis that occur more than 90 days after delivery of the prosthesis and that are required because of a change in the client’s condition are covered;

(e) Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the amount of the excess;

(f) Follow-up visits which occur more than 90 days after delivery and which do not involve modification or repair of the prosthesis are non-covered services;

(g) Replacement of a facial prosthesis is covered in cases of loss or irreparable damage or wear or when required because of a change in the client’s condition that cannot be accommodated by modification of the existing prosthesis;

(h) When a prosthesis is needed for adjacent facial regions, a single code must be used to bill for the item, whenever possible. For example, if a defect involves the nose and orbit, this should be billed using the hemi-facial prosthesis code and not separate codes for the orbit and nose. This would apply even if the prosthesis is fabricated in two separate parts.

(2) Documentation: The following must be submitted for prior authorization (PA):

(a) An order for the initial prosthesis and/or related supplies which is signed and dated by the ordering prescribing practitioner must be kept on file by the prosthetist/supplier and submitted with request for PA;

(b) A separate prescribing practitioner order is not required for subsequent modifications, repairs or replacement of a facial prosthesis;

(d) A photograph of the prosthesis and a photograph of the client without the prosthesis must be retained in the supplier’s record and must be submitted with the PA request;

(e) When code L8048 is used for a miscellaneous prosthesis or prosthetic component, the authorization request must be accompanied by a clear description and a drawing/copy of photograph of the item provided and the medical appropriateness;

(f) Requests for replacement, repair or modification of a facial prosthesis must include an explanation of the reason for the service;

(g) When replacement involves a new impression/moulage rather than use of a previous master model, the reason for the new impression/moulage must be clearly documented in the authorization request.

(3) Procedure Codes — Table 122-0680.

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97

Or. Admin. R. 410-122-0700 Negative Pressure Wound Therapy Pumps

(1) Indications and limitations of coverage and medical appropriateness — Initial Coverage: The Division may cover a negative pressure wound therapy (NPWT) pump and supplies on a monthly basis for up to four months on the most recent covered wound when either criterion (a) or (b) is met:

(a) Ulcers and wounds in the home setting or nursing facility:

(A) The client has a chronic Stage III or IV pressure ulcer, neuropathic (for example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 30 days) ulcer of mixed etiology;

(B) A complete wound therapy program described by criterion (i) and criteria (ii), (iii), or (iv), as applicable depending on the type of wound, must have been tried or considered and ruled out prior to application of NPWT:

(i) For all ulcers or wounds, the wound therapy program must include a minimum of all of the following general measures, which have either been addressed, applied, or considered and ruled out prior to application of NPWT:

(I) Documentation in the client's medical record of evaluation, care, and wound measurements by a licensed medical professional;

(II) Application of dressings to maintain a moist wound environment;

(III) Debridement of necrotic tissue if present;

(IV) Evaluation of and provision for adequate nutritional status;

(ii) For Stage III or IV pressure ulcers:

(I) Appropriate turning and positioning of the client;

(II) Use of a Group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (see 410-122-0400 Pressure Reducing Support Surfaces). If the ulcer is not on the trunk or pelvis, a Group 2 or 3 support surface is not required; and

(III) Appropriate management of the client's moisture and incontinence;

(iii) For neuropathic (for example, diabetic) ulcers:

(I) The client has been on a comprehensive diabetic management program, and;

(II) Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities;

(iv) For venous insufficiency ulcers:

(I) Compression bandages and/or garments have been consistently applied, and;

(II) Leg elevation and ambulation have been encouraged;

(b) Ulcers and wounds encountered in an inpatient setting:

(A) An ulcer or wound as described in subsection (1)(a) is encountered in the inpatient setting and, after wound treatments described in subsection (1)(a) have been tried or considered and ruled out, NPWT is initiated because the treating practitioner considers it the best available treatment option;

(B) The client has complications of a surgically created wound (for example, dehiscence) or a traumatic wound (for example, pre-operative flap or graft) where there is documentation of the medical appropriateness for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments (for example, other conditions of the client that will not allow for healing times achievable with other topical wound treatments);

(c) In either situation described in subsection (1)(b), NPWT will be covered when treatment continuation is ordered beyond discharge to the home setting;

(d) If criterion in subsection (1)(a) or (1)(b) above is not met, the NPWT pump and supplies are not covered;

(e) NPWT pumps (E2402) must be capable of accommodating more than one wound dressing set for multiple wounds on a client. A request for more than one NPWT pump per client for the same time period is not covered;

(f) For the purposes of this rule, a licensed health care professional may be a physician, physician's associate (PA), registered nurse (RN), licensed practical nurse (LPN), or physical therapist (PT). The practitioner must be licensed to assess wounds and/or administer wound care.

(2) Indications and limitations of coverage and medical appropriateness — Continued Coverage: For wounds and ulcers described in subsection (1)(a) or (1)(b), for clients placed on an NPWT pump and supplies, the Division will only approve continued coverage when the licensed medical professional does all the following duties:

(a) On a regular basis:

(A) Directly assesses the wound(s) being treated with the NPWT pump; and

(B) Supervises or directly performs the NPWT dressing changes;

(b) On at least a monthly basis, documents changes in the ulcer's dimensions and characteristics.

(3) Coverage for a NPWT pump and supplies ends when any of the following occur:

(a) Criteria in section (2) are not met;

(b) The treating physician determines that adequate wound healing has occurred for NPWT to be discontinued;

(c) Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is defined as improvement occurring in either surface area (length times width) or depth of the wound;

(d) Four months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using an NPWT pump in the treatment of the most recent wound. Coverage beyond four months will be given individual consideration based upon required additional documentation;

(e) Equipment or supplies are no longer being used for the client, whether or not by the physician's order.

(4) The Division will not cover NPWT pump and supplies if one or more of the following are present:

(a) Necrotic tissue with eschar in the wound, if debridement is not attempted;

(b) Untreated osteomyelitis within the vicinity of the wound;

(d) The presence of a fistula to an organ or body cavity within the vicinity of the wound.

(5) The Division will only cover NPWT pumps and their supplies that have been specifically designated as being qualified for use of HCPCS codes E2402, A6550 and A7000 via written instructions from the Medicare Pricing, Data Analysis and Coding (PDAC) contractor.

(6) The Division covers a maximum of 15 dressing kits (A6550) per wound per month, unless there is documentation that the wound size requires more than one dressing kit for each dressing change.

(7) The Division covers a maximum of 10 canister sets (A7000) per month, unless there is documentation evidencing a large volume of drainage (greater than 90 ml of exudate per day). For high-volume exudative wounds, a stationary pump with the largest capacity canister must be used. The Division does not cover excess use of canisters related to equipment failure (as opposed to excessive volume drainage).

(8) Guidelines:

(a) Equipment:

(A) Negative pressure wound therapy (NPWT) is the controlled application of subatmospheric pressure to a wound. Specifically, an electrical pump (described in the definition of code E2402) intermittently or continuously conveys subatmospheric pressure through connecting tubing to a specialized wound dressing (described in the descriptor of HCPCS code A6550). The dressing includes a resilient, open-cell foam surface dressing, sealed with an occlusive dressing that is meant to contain the subatmospheric pressure at the wound site and thereby promote wound healing. Drainage from the wound is collected in a canister (described in the definition of HCPCS code A7000);

(B) Code E2402 describes a stationary or portable NPWT electrical pump which provides controlled subatmospheric pressure that is designed for use with NPWT dressings, (A6550) to promote wound healing. Such an NPWT pump is capable of being selectively switched between continuous and intermittent modes of operation and is controllable to adjust the degree of subatmospheric pressure conveyed to the wound in a range from 25 to greater than or equal to 200 mm Hg subatmospheric pressure. The pump can sound an audible alarm when desired pressures are not being achieved (that is, where there is a leak in the dressing seal) and when its wound drainage canister (A7000) is full. The pump is designed to fill the canister to full capacity;

(b) Supplies:

(A) Code A6550 describes a dressing set which is used in conjunction with a stationary or portable NPWT pump (E2402), and contains all necessary components, including but not limited to a resilient, open-cell foam surface dressing, drainage tubing, and an occlusive dressing which creates a seal around the wound site for maintaining subatmospheric pressure at the wound;

(B) Code A7000 describes a canister set which is used in conjunction with a stationary or portable NPWT pump (E2402) and contains all necessary components, including but not limited to a container, to collect wound exudate. Canisters may be various sizes to accommodate stationary or portable NPWT pumps;

(B) Stage II — Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater;

(9) Documentation Requirements: Submit the following information with the prior authorization request:

(a) For initial coverage:

(A) A statement from the attending physician which describes the initial condition of the wound (including measurements) and the efforts to address all aspects of wound care as specified in subsection (1)(a);

(B) From the treating clinician, history, previous treatment regimens (if applicable), and current wound management for which an NPWT pump is being requested to include the following:

(i) Changes in wound conditions, including precise, quantitative measurements of wound characteristics (wound length and width (surface area), and depth), quantity of exudates (drainage), presence of granulation and necrotic tissue and concurrent measures being addressed relevant to wound therapy (debridement, nutritional concerns, support surfaces in use, positioning, incontinence control, etc.);

(ii) Dated photographs of ulcers or wounds with specific location(s) identified within the last 30 days;

(iii) Length of sessions of use;

(iv) Dressing types and frequency of change;

(v) Wound healing progress;

(b) For Continued Coverage:

(A) Progress notes from the attending physician within the last 30 days;

(B) Updated wound measurements and what changes are being applied to effect wound healing including information specified in paragraph (9)(a)(B);

(c) For both initial and continued coverage of an NPWT pump and supplies, any other medical records that corroborate that all criteria in this rule are met;

(d) When requesting quantities of supplies greater than those specified in this rule as the usual maximum amounts, include documentation supporting the medical appropriateness for the higher utilization.

(10) Table 122-0700.

[ED. NOTE: Tables referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 8-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 29-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 67-2023, minor correction filed 08/11/2023, effective 08/11/2023
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98

Or. Admin. R. 410-122-0710 Adaptive Car Seats and Travel Vests

(1) Indications and limitations of coverage and medical appropriateness: Adaptive car seats and travel vests provide safety during transportation in a vehicle for individuals of all ages with health care needs that cannot be met using conventional car seats.

(2) An adaptive car seat or travel vest that meets Federal Motor Vehicle Safety Standard 213 may be covered by the Division for an individual with a significant health condition for which a conventional car seat harness or its positioning is unsafe or physically incompatible as documented by one or more of the following functional limitations (list not all-inclusive):

(a) Inability to maintain an unsupported sitting position independently;

(b) Significant head and trunk instability;

(c) Significant hypotonicity, hypertonicity, spasticity, muscle spasm, contractures, seizure activity, or other physiological symptoms or events that result in uncontrollable movement and position changes and/or the inability to make positional correction;

(d) Bony or other fragility for which a conventional car seat harness use or positioning is unsafe;

(e) Fracture casting or post-surgical casting for which positioning in a conventional car seat is unsafe or physically incompatible;

(f) Congenital or acquired condition for which conventional car seat harness use and/or car seat positioning is incompatible (e.g. omphalocele, osteogenesis imperfecta, myelomeningocele, airway anomalies including tracheostomy, scoliosis or kyphosis); or

(g) Neurodevelopmental condition that renders conventional car seat safety features unsafe or ineffective.

(3) Prior Authorization (PA): The PA request must include the following documentation:

(a) The prescribing practitioner’s clinical documentation supporting the individual’s diagnosed medical condition(s) for an adaptive car seat or travel vest;

(b) A signed and dated evaluation by a licensed physical therapist, a licensed occupational therapist, or a National Highway Traffic Safety Administration (NHTSA) certified Child Passenger Safety Technician (CPST/CPS Technician) that is co-signed by a licensed practitioner with CPST-I certification in adaptive needs transportation, which includes detailed documentation of all of the following:

(A) The individual’s medical condition(s) for which the adaptive car seat or travel vest is needed;

(B) Description of what equipment is currently being used to transport the individual in a vehicle and why it no longer meets their medical needs;

(C) Interventions and less costly alternatives that have been tried and why those interventions were not successful (e.g., conventional car seats, vests, harnesses);

(D) Brand name and model number of the adaptive car seat or travel vest being requested (including each accessory);

(E) Acknowledgement that the requested adaptive car seat or travel vest is appropriate for use in the vehicle used to transport the client; and

(F) Client’s current height and weight, and the weight capacity and growth potential of the adaptive car seat model or travel vest requested.

(c) An order signed by the prescribing practitioner supporting the adaptive car seat (and accessories) or travel vest requested; and

(d) Manufacturer’s suggested retail price (MSRP) for the brand and model number of the adaptive car seat (including each accessory) or travel vest requested.

(4) The licensed physical therapist, licensed occupational therapist, CPS Technician (CPST), or licensed practitioner performing the evaluation must have no financial relationship with the DMEPOS provider.

(5) Reimbursement:

(a) HCPCS code E1399 shall be used for billing the adaptive car seats or travel vests and reimbursed in accordance with OAR 410-122-0186;

(b) All accessories shall be billed using HCPCS E1399 and reimbursed in accordance with OAR 410-122-0186;

(c) Certified CPS Technician visits for the initial equipment evaluation, installation and instructional training, and follow up visits to address a change in individual’s growth or development, a change in individual’s behavior, a change in vehicle/mode of transportation, or a change in medical need may be billed to the Division (Refer to (6) in this rule for coding descriptions and details) only when records of those evaluations and visits are reviewed and co-signed by a licensed practitioner with CPST-I certification in adaptive needs transportation.

(6) Documentation:

(a) For PA, submit documentation that supports coverage criteria and guidelines in this rule are met;

(b) Medical records and documentation to support the client meets criteria and conditions of coverage in this rule must be kept on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and shall be made available to the Division upon request.

(7) Procedure Codes and definitions:

(a) E1399 - Durable medical equipment, miscellaneous (adaptive car seat, accessories, travel vest); - PA Required

(b) 99204 - New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more (Initial assessment and evaluation of client and vehicle performed by certified CPST - provider type specialty 321);

(c) 99213 - Established patient office or other outpatient visit with low level of decision making, if using time, 20 minutes or more (Follow up visit performed by certified CPST - provider type specialty 321);

(d) 99214 - Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more (Follow up visit performed by certified CPST - provider type specialty 321);

(e) 99215 - Established patient office or other outpatient visit with high level of medical decision making, if using time, 40 minutes or more to address a change in the client’s growth or development, a change in client’s behavior, a change in vehicle/mode of transportation, or a need to change from a conventional seat to an adaptive car seat or travel vest (Reevaluation/reassessment visit performed by a certified CPST - provider type specialty 321).

(f) A CPST, also known as a CPS Technician, is defined as a professional who is currently NHTSA certified by Safe Kids Worldwide and Safe Travel for all Children (STAC) in Transporting Children with Special Healthcare Needs. A CPST must be trained in adaptive needs transportation and perform services in accordance with the National CPS Board’s Child Passenger Safety Technician Code of Conduct.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 101-2023, adopt filed 12/29/2023, effective 01/01/2024

Or. Admin. R. 410-122-0720 Pediatric Wheelchairs

(1) Indications and limitations of coverage and medical appropriateness:

(a) For clients under the age of 21: The EPSDT program covers all medically necessary and medically appropriate services needed to correct or ameliorate health conditions, or to improve the client’s ability to grow, develop, or participate in school, regardless of placement on or inclusion in the Prioritized List of Health Services. Coverage for a pediatric wheelchair for clients under age 21 shall be based on an individual review for medical necessity and medical appropriateness, as defined in OAR 410-151-0001.

(b) For clients age 21 and older - The Division may cover a pediatric wheelchair when all of the following criteria are met:

(A) The client has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in or out of the home. MRADLs include but are not limited to tasks such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation is one that:

(i) Prevents the client from completing an MRADL entirely; or

(ii) Places the client at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform a MRADL; or

(iii) Prevents the client from completing an MRADL within a reasonable timeframe.

(B) An appropriately fitted cane or walker cannot sufficiently resolve the client’s mobility limitation;

(C) If the client will be using the wheelchair in the home, the client’s home provides adequate maneuvering space, maneuvering surfaces, and access between rooms for use of the pediatric wheelchair that is being requested;

(D) Use of a pediatric wheelchair will significantly improve the client’s ability to participate in MRADLs. For clients with severe cognitive and physical impairments, participation in MRADLs may require the assistance of a caregiver;

(E) The client is willing to use the requested pediatric wheelchair on a regular basis;

(F) The client has either:

(i) Sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the requested pediatric wheelchair in the home and community during a typical day. Proper assessment of upper extremity function shall consider limitations of strength, endurance, range of motion, coordination, presence of pain, and deformity or absence of one or both upper extremities; or

(ii) A caregiver who is available, willing, and able to provide assistance with the wheelchair.

(c) Only when conditions of coverage as specified in section (1)(a) of this rule are met may the Division authorize a pediatric wheelchair for any of the following situations:

(A) When the wheelchair can be reasonably expected to improve the client’s ability to complete MRADLs by compensating for other limitations in addition to mobility deficits and the client is compliant with treatment:

(i) Besides MRADLs deficits, when other limitations exist, and these limitations can be ameliorated or compensated sufficiently such that the additional provision of a pediatric wheelchair will be reasonably expected to significantly improve the client’s ability to perform or obtain assistance to participate in MRADLs, a pediatric wheelchair may be considered for coverage;

(ii) If the amelioration or compensation requires the client's compliance with treatment, for example medications or therapy, substantive non-compliance whether willing or involuntary can be grounds for denial of pediatric wheelchair coverage if it results in the client continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of a pediatric wheelchair.

(B) For a purchase request, when a client’s current wheelchair is no longer medically appropriate or repair or modifications to the wheelchair exceed replacement cost;

(C) When a covered, client-owned wheelchair is in need of repair (for one month’s rental of a wheelchair). See OAR 410-122-0184 Repairs, Maintenance, Replacement, Delivery and Dispensing.

(d) A pediatric tilt-in-space wheelchair (E1231- E1234) may be covered when a client meets all of the following conditions:

(A) A standard base with a reclining back option will not meet the client’s needs;

(B) Requires assistance for transfers;

(C) The plan of care addresses the need to change position at frequent intervals, and the client is not left in the tilt position most of the time; and

(D) Has one of the following:

(i) High risk of skin breakdown;

(ii) Poor postural control, especially of the head and trunk;

(iii) Hyper/hypotonia;

(iv) Need for frequent changes in position and has poor upright sitting.

(e) One month’s rental for a manual pediatric tilt-in-space wheelchair (E1231-E1234) may be covered for a client residing in a nursing facility when all of the following conditions are met:

(A) The anticipated nursing facility length of stay is 30 days or less;

(B) The conditions of coverage for a manual tilt-in-space wheelchair as described in section (1) (d) (A) (D) are met;

(D) Coverage is limited to one month’s rental.

(f) The Division does not reimburse for another wheelchair if the client has a medically appropriate wheelchair, regardless of payer;

(g) If the client will be using the wheelchair in the home, the client’s living quarters must be able to accommodate and allow for the effective use of the requested wheelchair. The Division does not reimburse for adapting living quarters;

(h) The Division may not cover services or upgrades that primarily allow performance of leisure or recreational activities. Such services include but are not limited to backup wheelchairs, backpacks, accessory bags, clothing guards, awnings, additional positioning equipment if wheelchair meets the same need, custom colors, and wheelchair gloves;

(i) Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair, as well as support services such as emergency services, delivery, set-up, pick-up and delivery for repairs/modifications, education, and ongoing assistance with the use of the wheelchair;

(j) Power mobility devices and related options and accessories must be supplied by a DMEPOS provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client;

(k) The ATP must be employed by a provider in a full-time, part-time, or contracted capacity as is acceptable by state law. The provider’s ATP, if part-time or contracted, must be under the direct control of the provider;

(l) Documentation must be complete and detailed enough so a third party would be able to understand the nature of the provider’s ATP involvement, if any, in the licensed/certified medical professional (LCMP) specialty evaluation;

(m) The ATP may not conduct the provider evaluation at the time of delivery of the power mobility device to the client’s residence;

(n) A Group 5 (Pediatric) power wheelchair (PWC) with Single Power Option (K0890) or with Multiple Power Options (K0891) may be covered when the coverage criteria for a PWC in OAR 410-122-0325, Power Wheelchair Base, are met.

(n) The delivery of a PWC must be within 120 days following completion of the face-to-face examination with the physician;

(o) A PWC may not be ordered by a podiatrist.

(p) For more information on coverage criteria regarding repairs and maintenance, see OAR 410-122-0184 Repairs, Maintenance, Replacement, Delivery and Dispensing.

(2) Coding Guidelines:

(a) For individualized wheelchair features that are medically appropriate to meet the needs of a particular client, use the correct codes for the wheelchair base, options, and accessories (see OAR 410-122-0340 Wheelchair Options/Accessories);

(b) For wheelchair frames that are modified in a unique way to accommodate the client, submit the code for the wheelchair base used, and submit the modification with code K0108 (wheelchair component or accessory, not otherwise specified);

(c) Wheelchair "poundage" (pounds) represents the weight of the usual configuration of the wheelchair with a seat and back, but without front riggings.

(3) Documentation requirements:

(a) Functional mobility evaluation:

(A) Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers must submit medical documentation that supports conditions of coverage in this rule are met for purchase and modifications of all covered, client-owned pediatric wheelchairs;

(B) Information must include but is not limited to:

(i) Medical justification, needs assessment, order, and specifications for the wheelchair, completed by a PT, OT, or treating physician. The individual who provides this information must have no direct or indirect financial relationship, agreement, or contract with the DMEPOS provider requesting authorization;

(ii) Client identification and rehab technology supplier identification information that may be completed by the DMEPOS provider; and

(iii) Signature and date by the treating physician and PT or OT.

(C) If the information on this form includes all the elements of an order, the provider may submit the completed form in lieu of an order.

(b) Additional documentation:

(A) Information from a PT, OT, or treating physician that specifically indicates:

(i) The client’s mobility limitation and how it interferes with the performance of activities of daily living;

(ii) Why a cane or walker cannot sufficiently resolve the client’s mobility limitations.

(B) Pertinent information from a PT, OT, or treating physician about the following elements that support coverage criteria are met for a pediatric wheelchair, only relevant elements need to be addressed:

(i) Symptoms;

(ii) Related diagnoses;

(iii) History:

(I) How long the condition has been present;

(II) Clinical progression;

(III) Interventions that have been tried and the results;

(IV) Past use of walker, pediatric wheelchair, power-operated vehicle (POV), or PWC and the results.

(iv) Physical exam:

(I) Weight;

(II) Impairment of strength, range of motion, sensation, or coordination of arms and legs;

(III) Presence of abnormal tone or deformity of arms, legs, or trunk;

(IV) Neck, trunk, and pelvic posture and flexibility;

(V) Sitting and standing balance.

(v) Functional assessment indicating any problems with performing the following activities including the need to use a cane, walker, or the assistance of another individual:

(I) Transferring between a bed, chair, and a wheelchair or power mobility device;

(II) Walking around their home or community including information on distance walked, speed, and balance.

(C) Documentation from a PT, OT, or treating physician that clearly distinguishes the client’s abilities and needs within the home from any additional needs for use outside the home;

(D) For all requested equipment and accessories, the manufacturer’s name, product name, model number, standard features, specifications, dimensions, and options, including growth capabilities;

(F) If client will be using the wheelchair in the home, the DMEPOS provider or practitioner must perform an on-site, written evaluation of the client’s living quarters, prior to delivery of the wheelchair. This assessment must support that the client’s home can accommodate and allow for the effective use of a wheelchair. This assessment must include but is not limited to evaluation of physical layout, doorway widths, doorway thresholds, surfaces, counter or table height, accessibility (e.g., ramps), electrical service, etc.; and

(G) All HCPCS codes, including the base, options and accessories, whether prior authorization (PA) is required or not, that will be billed separately.

(c) A written order by the treating physician, identifying the specific type of pediatric wheelchair needed. If the order does not specify the type requested by the DMEPOS provider on the authorization request, the provider must obtain another written order that lists the specific pediatric wheelchair that is being ordered and any options and accessories requested. The DMEPOS provider may enter the items on this order. This order must be signed and dated by the treating physician, received by the DMEPOS provider, and submitted to the authorizing authority;

(d) For a PWC request, see OAR 410-122-0325 Power Wheelchair Base for documentation requirements;

(e) Any additional documentation that supports indications of coverage are met as specified in this policy;

(f) For a manual wheelchair rental, submit all of the following:

(A) A written order from the treating physician, identifying the specific type of manual wheelchair needed:

(ii) The DMEPOS provider may enter the items on this order;

(iii) This order must be signed and dated by the treating physician, received by the DMEPOS provider, and submitted to the authorizing authority.

(B) HCPCS codes;

(C) If the client will be using the wheelchair in the home, documentation from the DMEPOS provider that supports that the client’s home can accommodate and allow for the effective use of the requested wheelchair.

(g) The above documentation must be kept on file by the DMEPOS provider; and

(h) Documentation that the coverage criteria have been met must be present in the client’s medical records, and this documentation must be made available to the Division upon request.

(4) Table 410-122-0720 – Pediatric Wheelchairs.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 30-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 12-2018, amend filed 03/07/2018, effective 03/08/2018
DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18
DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03

Or. Admin. R. 410-122-0730 Continuous Glucose Monitoring Equipment and Supplies

(1) Indications and Limitations of Coverage and Medical Appropriateness:

(a) The Division shall cover personal, real-time continuous glucose monitoring (CGM) equipment and supplies for clients with a diagnosis of type 1 diabetes mellitus, type 2 diabetes mellitus, or gestational diabetes when criteria in the Prioritized List of Health Services Continuous Glucose Monitoring Guideline Note are met;

(b) Continuous glucose monitoring equipment and supplies (E2102, E2103, A4238, A4239, A9276, A9277, A9278) require prior authorization (PA) with clinical documentation to support that all criteria in OAR Ch. 410 Div. 122 DMEPOS rules and Table 122-0730 are met;

(c) Initial authorization shall be limited to six (6) months from the date of Division’s authorization. Continued use beyond the initial six (6) months authorization requires the provider send to the Division current medical documentation of a client follow up visit with the treating practitioner which supports that there continues to be a medical need, that the requirements of this rule are met, and the client is regularly utilizing the CGM and the data from the CGM to adjust insulin; regularly utilizing means that the client used the device for at least 50 percent of the time since the date of the initial authorization;

(d) CGM equipment must be FDA approved for the age of the client;

(e) Insulin pumps with integrated CGM function require prior authorization and must meet criteria in this rule and OAR 410-122-0525;

(f) The Division considers all other applications of real-time CGM to be investigational as the effectiveness of its use has not been established in peer-reviewed professional literature;

(2) Therapeutic/Non-adjunctive CGM devices (E2103 and A4239) are used to make treatment decisions and replaces standard blood glucose monitoring and related supplies. Standard blood glucose monitoring and supplies (E0607, E2100. E2101, A4233, A4234, A4236, A4244. A4245, A4246, A4247, A4250, A4253. A4255. A4257, A4258, A4259) cannot be billed separately to the Division on any day that falls within the CGM authorization time period when the client is using non-adjunctive CGM. This is a duplication of services;

(3) Non-therapeutic/Adjunctive CGM devices (E2102 and A4238) do not replace standard blood glucose monitoring. These supplies may be billed separately;

(4) PA requests for CGM systems that are FDA approved but are not considered DME (i.e., CGM systems that use smart phone exclusively for monitor/receiver) will be reviewed on a case-by-case basis. Clinical documentation from the treating practitioner, specific to the client, must demonstrate that all other covered CGM alternatives have been considered, tried and failed, or reasonably expected to fail;

(5) Providers may not use A9276, A9277, or A9278 to bill supplies for any CGM device coded as an adjunctive CGM (E2102) or non-adjunctive CGM (E2103) device. Providers shall refer to the product classification list on the Pricing, Data Analysis and Coding (PDAC) contractor website for coding verification;

(6) Reasonable useful lifetime (RUL) of CGM is no less than three (3) years;

(a) Computation of the useful lifetime is based on when the CGM is delivered to the client, not the age of the device;

(b) If there is a medical need to replace a CGM device within the RUL period, the provider must submit documentation to corroborate the malfunction of the CGM and records to support the individual’s medical necessity and appropriateness for the new device and ongoing treatment for a case-by-case review.

(7) Documentation:

(a) For PA, submit documentation that supports coverage criteria and guidelines in this rule are met;

(8) See Table 122-0730 for billing codes.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025
DMAP 31-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, adopt filed 12/29/2023, effective 01/01/2024

Division 123 DENTAL/DENTURIST SERVICES

Or. Admin. R. 410-123-1060 Definitions and Acronyms

The acronyms and definitions within this rule specifically pertain to dental services. This rule does not include an exhaustive list of acronyms and definitions that apply to dental services. All Authority rules are intended to be used in conjunction with the General Rules for Oregon Health Plan (OHP) OAR 410 division 120 and the OAR 410 division 141. Other acronyms and definitions that apply to dental services are found in OARs 410-141-3500, 410-120-0000, 410-200-0015, and Chapter 410, Division 130.

(1) “Alveoplasty” is a dental procedure often performed following a tooth extraction, to help recreate the natural contour of the gums and jaw that may have been lost due to bone loss from tooth extraction, or for another reason.

(2) “Ancillary Services” has the meaning provided in OAR 410-120-0000.

(3) “Anesthesia Services” has the meaning provided in OAR 410-120-0000.

(4) “Anterior teeth” are referred to as the front teeth. Permanent (adult) teeth are also referred to by numbers and differentiated by upper and lower:

(a) The upper anterior teeth are indicated by the numbers 6, 7, 8, 9, 10, 11; and

(b) The lower anterior teeth are indicated by the numbers 22, 23, 24, 25, 26, 27.

(5) “Apexification” is a dental treatment provided on permanent teeth when the roots of the teeth are incompletely formed, to encourage development and formation of the root.

(6) “Apicoectomy” involves the removal of a tooth’s root tip and surrounding tissue.

(7) “Billing” definition and requirements are provided in OAR 410-120-1280.

(8) “By Report” (BR) has the meaning provided in OAR 410-120-0000.

(9) “Canine teeth” are anterior teeth that are pointed. In addition to numbered permanent (adult) teeth, primary (baby) teeth are also referred to by letters and differentiated between upper and lower:

(a) Primary upper canine teeth are indicated by the letters C, H;

(b) Primary lower canine teeth are indicated by the letters M, R;

(d) Permanent lower canine teeth are indicated by the numbers 22, 27.

(10) “Clinically Appropriate” has the meaning provided in OAR 410-120-0000.

(11) “Compact Of Free Association (COFA)” Dental Program is a dental-only enrollment type under the Oregon Health Plan (OHP) as defined in OAR 410-200-0445.

(12) “Composite restorations” are white, tooth-colored fillings.

(13) “Concurrent needs” means simultaneously having a diagnosed need and other characteristics as listed that may affect service delivery.

(14) “Coordinated Care Organization (CCO)” has the meaning provided in OAR 410-141-3500.

(15) “Covered Services” has the meaning provided in OAR 410-120-0000.

(16) “Current Dental Terminology (CDT)” codes are the alphanumeric codes that identify a specific dental procedure, as designated by the federal government, and used by the American Dental Association.Current Dental Terminology, © 2025 American Dental Association. All rights reserved.

(17) “Dental” means teeth and supporting structures.

(18) “Dental Hygienist” has the meaning provided in OAR 410-120-0000.

(19) “Dental Hygienist with an Expanded Practice Dental Hygiene (EPDH) Permit” has the meaning provided in OAR 410-120-0000.

(20) “Dental Practitioner (Practitioner)” means an individual licensed pursuant to state law to engage in the provision of dental services within the scope of the practitioner’s license and certification.

(21) “Dental Services” means services provided within the scope of practice as defined under state law, by or under the supervision of a dentist or dental hygienist or denture services provider within the scope of practice as defined under state law, by a denturist or dental hygienist with an Expanded Practice Permit (EPP).

(22) “Dental Subcontractor” has the meaning provided in OAR 410-120-0000.

(23) “Dental Therapist” has the meaning provided in OAR 410-120-0000.

(24) “Dentally Appropriate” has the meaning provided in OAR 410-120-0000.

(25) “Dentist” has the meaning provided in OAR 410-120-0000.

(26) “Denturist” has the meaning provided in OAR 410-120-0000.

(27) “Distant Site” means the site where a dentist is being contacted for consultation by the originating site.

(28) “Documentation” means dental services documentation which meets the requirements of the Oregon Dental Practice Act statutes, administrative rules for member records, and requirements of OAR 410-120-1360 Requirements for Financial, Clinical and Other Records, and any other documentation as outlined in OAR Chapter 410, Division 123 (Dental/Denturist Services).

(29) “Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)” means the program described in OAR 410-151-0000.

(30) “EPSDT Beneficiary” has the meaning provided in OAR 410-151-0001.

(31) “Eligibility” has the meaning provided in OAR Chapter 410, Division 200.

(32) “Emergency Dental Condition” means any incident involving the teeth or gums which may require immediate treatment to stop ongoing tissue bleeding, alleviate severe and sudden pain or infection, treat unusual swelling of the face or gums, or to preserve an avulsed (knocked out) tooth. For additional criteria, refer to “Emergency Medical Condition” provided in 410-120-0000.

(33) “Emergency Dental Services” has the same meaning as “Dental Emergency Services” provided in OAR 410-120-0000. This meaning is synonymous with “emergency dental care” and “emergency oral health care.”

(34) “Endodontic” means relating to the inner tissues of teeth, otherwise known as the pulp or nerve. Endodontic treatments include pulpal therapy and root canal therapy.

(35) “Fee-for-Service Provider” has the meaning provided in OAR 410-120-0000.

(36) “First Tooth” is a curriculum aimed to reduce early childhood caries in Oregon.

(37) “Fillings” are provided when an area of decay on a tooth is removed by a dental provider, leaving a hole or space that is then filled with a material.

(38) “Gingivectomy” is the surgical removal of diseased gum tissue, to prevent damage to the bone.

(39) “Gingivoplasty” is the surgical reshaping of gum tissue around the teeth.

(40) “Health Care Interpreter (HCI)” Certified or Qualified, has the meaning given to those terms in ORS 413.550.

(41) “Hemoglobin A1c (HbA1c) Testing” is a measure of glucose attached to red blood cells and directly relates to average blood glucose levels.

(42) “Health Evidence Review Commission (HERC)” has the meaning provided in OAR 410-120-0000.

(43) “Incisors” are anterior (front) teeth that have single, narrow edges. They are the four front, upper teeth, and the four front lower teeth.

(a) Primary upper incisors are indicated by the letters D, E, F, G;

(b) Primary lower incisors are indicated by the letters N, O, P, Q;

(d) Permanent lower incisors are indicated by the numbers 23, 24, 25, 26.

(44) “Malocclusion” is a misalignment or incorrect relation of the upper and lower teeth when the jaw is closed.

(45) “Mandibular” refers to the lower jaw and the lower teeth.

(46) “Maxillary” refers to the upper jaw and the upper teeth.

(47) “Maxillofacial” means relating to the face, head, neck or jaw. Treatments may be necessary due to trauma, disease, or congenital defects.

(48) “Medical Practitioner” means an individual licensed pursuant to state law to engage in the provision of medical services within the scope of the practitioner’s license and certification.

(49) “Medically Necessary” has the meaning provided in OAR 410-120-0000.

(50) “Medicament” means a substance or combination of substances intended to be pharmacologically active, specially prepared to be prescribed, dispensed, or administered to prevent or treat disease.

(51) “Oral Health” refers to the health of teeth, gums, lips, tongue, inner cheeks, and the entire oral-facial system that allows us to smile, speak, and chew.

(52) “Oral Health Services” refers to services offered to members for their improved oral health. The workforce involved in the services offered includes (but is not limited to) delivery systems staff, educational programs staff, licensed dental providers, dental assistants, and primary care providers such as doctors, nurses, and medical assistants.

(53) “Oregon Health Authority (Authority)” means the organization that administers Medicaid in Oregon.

(54) “Oregon Health Plan (OHP)” is the Medicaid program in Oregon, and has the meaning provided in OAR 410-120-0000.

(55) “Originating Site” means the site where the member is located, and dental care providers are working and performing services in conjunction with a dentist who is not at that site, while using telehealth technology.

(56) “Periapical X-rays” capture an image of an entire tooth, from the crown to the root tip.

(57) “Periodontal scaling” and “root planing” refer to non-surgical treatments to remove plaque and tartar from teeth roots and gums.

(58) “Periodontal” refers to the soft tissues supporting and surrounding teeth.

(59) “Permanent teeth”, often referred to as adult teeth, are the second set of teeth people get. There are 32 permanent teeth which include incisors, canines, and premolars, and molars. They are identified by the numbers 1 through 32.

(60) “Posterior teeth” are referred to as the back teeth:

(a) Permanent upper posterior teeth are indicated by the numbers 1, 2, 3, 4, 5, 12, 13, 14, 15, 16;

(b) Permanent lower posterior teeth are indicated by the numbers 17, 18, 19, 20, 21, 28, 29, 30, 31, 32;

(d) Primary lower posterior teeth are indicated by the letters S, T, K, L.

(61) “Practitioner” has the meaning provided in OAR 410-120-0000.

(62) “Premolars” are permanent teeth that are positioned between the canines and molars:

(a) The upper premolar teeth are indicated by the numbers 4, 5, 12, 13; and

(b)The lower premolar teeth are indicated by the numbers 20, 21, 28, 29.

(63) “Prescriptions” means services as outlined in OAR 410-121-0144.

(64) “Primary Teeth” are also known as baby teeth. These are the first set of teeth that people get. There are 20 primary teeth that shall exfoliate (fall out) as the permanent teeth grow in. Primary teeth are indicated by the letters A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T.

(65) “Prior Authorization (PA)” has the meaning provided in OAR 410-120-0000.

(66) “Prioritized List of Health Services (Prioritized List)” has the meaning provided in OAR 410-120-0000.

(67) “Procedure Codes” means Current Dental Terminology (CDT), unless otherwise noted. Codes listed in this rule and other documents incorporated in rule by reference are subject to change by the American Dental Association (ADA) without notification.

(68) “Prophylaxis” is a dental service to thoroughly clean the teeth.

(69) “Prosthodontics” refers to the replacement of missing or damaged teeth with artificial devices, most commonly dentures.

(70) “Provider” has the meaning provided in OAR 410-120-0000.

(71) “Pulpal regeneration” is a dental treatment used to restore the pulp of a diseased or damaged tooth.

(72) “Pulpal therapy” involves removing pulp from the crown of a primary tooth and treating it with medicament.

(73) “Record retention” means the schedule whereby providers must keep clinical information and financial records on file.

(74) “Smiles for Life” is a national oral health curriculum that Oregon Medicaid has adopted to improve oral health access.

(75) “Standard of Practice” means what reasonable and prudent practitioners may do in the same or similar circumstances.

(76) “Teledentistry” means using electronic and telecommunications technologies, for the distance delivery of dental care services and clinical information designed to improve a member’s health status and to enhance delivery of the health care services and clinical information.

(77) “Telehealth” has the meaning provided in OAR 410-120-0000.

(78) “Third Party Resources (TPR)” has the meaning provided in OAR 410-120-1280.

(79) “Urgent Dental Care” means the management of conditions that require prompt attention to relieve pain and/or risk of infection, and to alleviate the burden on hospital emergency departments. Urgent dental care is distinguished from emergency dental care in that urgent dental care requires prompt but not immediate treatment. Examples include dull toothache, mildly swollen gums, or small chips or cracks in teeth.

(80) “Veterans Dental Program” is a dental-only enrollment type under the Oregon Health Plan (OHP) as defined in OAR 410-200-0450.

(81) "Young Adults with Special Health Care Needs (YSHCN)” is a benefit eligibility program as defined in OAR 410-200-0455.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 59-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 79-2023, amend filed 09/26/2023, effective 10/01/2023
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 24-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 61-2020, amend filed 12/11/2020, effective 01/01/2021
DMAP 34-2016, f. 6-30-16, cert. ef. 7-1-16
DMAP 36-2014, f. & cert. ef. 6-27-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13
DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12
DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 16-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08
OMAP 49-2004, f. 7-28-04, cert. ef. 8-1-04
OMAP 48-2002, f. & cert. ef. 10-1-02
OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 23-1999, f. & cert. ef. 4-30-99
OMAP 28-1998, f. & cert. ef. 9-1-98
OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98
HR 3-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-123-1160 Prior Authorization

(1) The Authority covers the following services only with Prior Authorization (PA) approval:

(a) Crowns:

(A) Porcelain fused to metal (D2751, D2752); and

(B) Porcelain ceramic (D2740);

(b) Crown repair necessitated by restorative material failure (D2980), covered only for anterior teeth;

(d) Complete dentures;

(e) Immediate dentures;

(f) Partial dentures;

(g) Immediate partial dentures;

(h) Prefabricated post and core (D2954);

(i) Fixed partial denture repairs (D6980);

(j) Skin graft (D7920);

(k) Comprehensive Orthodontic treatment (D8070, D8080, D8090, D8091);

(l) Hospital dentistry (Refer to OAR 410-123-1490);

(m) Oral surgical services, when performed in an:

(A) Ambulatory surgical center (ASC); or

(B) Outpatient or inpatient hospital setting and related anesthesia (Refer to OAR 410-130-0200); and

(n) Maxillofacial surgeries, in some instances (Refer to OAR 410-130-0200).

(2) The Authority does not require PA for outpatient or inpatient services related to a “Dental Emergency Condition” as defined in OAR 410-123-1060:

(a) The member’s medical record must document any appropriate clinical information that supports the need for the hospitalization; and

(b) Refer to the Prioritized List of Health Services for funded emergency dental service codes.

(3) The frequency allowed for the following services may be increased with approved PA .

(a) Frequencies of Periodontal scaling and root planing (D4341, D4342), and scaling in the presence of generalized moderate to severe inflammation (D4346) may be increased from the once (1) every two (2) years limitation when:

(A) Medically necessary and dentally appropriate due to periodontal disease found during pregnancy or 12 months postpartum; and

(B) Documentation in the member’s record that supports the need for increased scaling and root planing;

(b) The frequency of Periodontal maintenance (D4910) may be increased from the once (1) in six (6) months limitation when:

(A) Medically necessary and dentally appropriate due to periodontal disease found during pregnancy or 12 months postpartum;

(B) Documentation in the member’s record documents the need. Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth and clinical attachment loss charting and radiographs; and

(C) Periodontal maintenance is covered only following periodontal therapy (surgical or non-surgical) that is documented to have occurred within the past three (3) years.

(4) Hospital dentistry always requires PA for the medical services provided by the facility:

(a) If a member is enrolled in a CCO with plan type CCOA:

(A) The dental subcontractor or dental provider is responsible for:

(i) Contacting the CCO for PA requirements and arrangements; and

(ii) Submitting documentation to the CCO associated with the member record.

(B) The CCO must review the documentation and discuss any concerns they have, contacting the dentist as needed; and

(C) The total response time must not exceed seven (7) calendar days from the date of receipt of all required documentation for routine dental care and must follow urgent or emergent dental care timelines.

(b) If a member is enrolled in a CCO with plan type CCOB;

(A) The dentist is responsible for:

(i) Contacting the CCO for PA requirements and arrangements; and

(ii) Submitting documentation to the CCO associated with the member record.

(B) The CCO shall review the documentation and discuss any concerns they have, contacting the dentist as needed. This allows for mutual plan (CCO and FFS) involvement and monitoring; and

(C) The CCO is responsible for payment of all facility and anesthesia services. The FFS program is responsible for payment of all dental services.

(A) The dentist is responsible for sending, by secure email or faxing, documentation and a completed American Dental Association (ADA) form to the Authority (Refer to the Dental Services Provider Guide);

(B) The member must have prior approval from the CCO for dental services, and from the Authority for the facility payment;

(D) The CCO is responsible for payment of all dental services; and

(E) The Authority shall issue a decision on PA requests within seven (7) calendar days of date received.

(d) If a member is enrolled in Fee-for-Service for both physical health and dental health or enrolled in the Coordinated Care Organization plan type CCOE, the:

(A) Dental provider is responsible for sending, by secure email or faxing, documentation, and a completed ADA form to the Authority (Refer to the Dental Services Provider Guide); and

(B) Authority is responsible for payment of all facility, anesthesia services and dental services.

(5) How to request PA:

(a) Refer to www.oregon.gov/oha/HSD/OHP/Pages/PA.aspx or the Dental Services Provider Guide for specific instructions and forms to use. PA requests made by telephone or sent through the mail are not accepted;

(b) Submitted documentation must support the medical justification for the service. The PA request must contain:

(A) A cover sheet detailing relevant provider and recipient Medicaid numbers;

(B) Requested date(s) of service;

(D) Amount of service or units requested; and

(E) Any additional clinical information supporting medical justification for the services requested.

(c) The Authority recommends inclusion of appropriate digital radiographs with the original PA request submission; and other clinical information that justifies the treatment. Radiographs must be:

(A) Correctly identified of diagnostic quality; and

(B) Clearly labeled with the dental provider’s name and address and the member's name.

(6) The Authority shall issue a decision on PA requests within seven (7) calendar days upon receipt of the request. The Authority shall provide PA for services when:

(a) The prognosis is favorable, which refers to a;

(A) Prediction that an individual’s health condition is likely to improve or lead to a positive outcome; and

(B) Determination made by a healthcare provider based on medical evidence;

(b) The treatment is practical;

(d) A lesser-cost procedure may not achieve the same ultimate results.

(7) PA approval does not guarantee member eligibility or reimbursement. It is the responsibility of the provider to check the member's eligibility on each date of service.

(8) The Authority may seek a general practice or specialist consultant for:

(a) Professional review to determine if a PA shall be approved; and

(b) Shall deny PA if the consultant decides that the clinical information furnished does not support the treatment of services.

History

Statutory/Other Authority: ORS 413.042, ORS 414.065 & 414.707
Statutes/Other Implemented: ORS 414.065 & 414.707
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 60-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 8-2022, minor correction filed 02/04/2022, effective 02/04/2022
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 61-2020, amend filed 12/11/2020, effective 01/01/2021
DMAP 28-2013(Temp), f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13
DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13
DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 16-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08
OMAP 48-2002, f. & cert. ef. 10-1-02
OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 23-1999, f. & cert. ef. 4-30-99
HR 32-1994, f. & cert. ef. 11-1-94
HR 3-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-123-1250 HbA1c Testing

(1) The Authority covers Hemoglobin A1c (HbA1c) testing for at risk members per scope of practice for Oregon licensed oral health providers.

(2) Although not presumed to be a standard of care, testing serves as a resource for licensed oral health providers which supports identification of those members with HbA1c levels that are above the “normal range", and that can affect periodontal status, wound healing, infection control and other conditions of the oral environment.

(3) Licensed oral health providers must share the HbA1c test results with the member’s primary care provider (PCP) to promote care collaboration and avoid duplication, and:

(a) Establish bi-directional communication with the member’s PCP to communicate test results and initiate a referral for evaluation, diagnosis, treatment, and collaboration of care; and

(b) Communicate progress of treatment and oral health status.

(4) Licensed oral health providers must comply with OAR 410-130-0680, as it pertains to blood testing, and 42 CFR §493 and OAR 333-024-0005 through 333-024-0055, as it pertains to Clinical Laboratory Improvement Amendments (CLIA):

(a) Information about CLIA in Oregon including enrollment requirements and processes is located on the Authority’s Clinical Laboratory Regulation webpage https://www.oregon.gov/oha/PH/LaboratoryServices/ClinicalLaboratoryRegulation/Pages/index.aspx;

(b) In order to perform HbA1c testing, Oregon licensed oral health providers and facilities must apply for a Certificate of Waiver (CMS-116 application form), available on the CLIA webpage; and

(c) Waived tests are not exempt from CLIA certification. For more information, refer to https://www.cms.gov/medicare/quality/clinical-laboratory-improvement-amendments.

(5) In determining the need for HbA1c testing, licensed oral health providers must use best clinical judgement when considering member risk factors based on appropriate, consensus-based guidelines.

(6) Release of Information (ROI):

(a) Licensed oral health providers must ensure a member’s ROI is on file in the member’s record;

(b) If the member does not have a PCP, licensed oral health providers must:

(A) Inform the member of the test findings and direct them toward resources containing more information and encourage the member to become a patient of record with a PCP for their other health needs; and

(B) Document actions in the member’s record, with follow-up at the next visit.

(d) Licensed oral health providers must provide sufficient information regarding the purpose of the test and the procedure, including their relevance to both oral and general health, so that a member can make an informed decision; and

(e) Members may decline testing.

History

Statutory/Other Authority: ORS 679.543 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 63-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 65-2019, adopt filed 12/26/2019, effective 01/01/2020

Or. Admin. R. 410-123-1260 Temporary rule language in effect until 09/22/2026. Coverage, Limitations, Exclusions

(1) The Oregon Health Authority (Authority) offers Medicaid dental/denturist benefits on a Fee-For-Service (FFS) basis:

(a) Providers must be licensed to practice dentistry and enrolled as a Medicaid provider as required by OAR 410-120-1260;

(b) All billing and rendering providers must comply with OAR Chapter 410 Division 120 rules and these Chapter 410, Division 123 rules which provide direction in the delivery of dental services and in the preparation of dental care claims; and

(2) This rule incorporates the Oregon Health Evidence Review Commission (HERC) Prioritized List of Health Services (Prioritized List), included through the stated Funding Line, unless otherwise excluded in rule, and including all line items, diagnostic and treatment codes, guideline notes, statements of intent, coding specifications and annotations (refer to OAR 410-141-3830):

(a) Providers must comply with the Authority rules for dental services covered by the Oregon Health Plan (OHP) which include the:

(A) Funded lines on the Prioritized List as defined in OAR 410-141-3830 found at www.oregon.gov/oha/hpa/dsi-herc/pages/prioritized-list.aspx; and

(B) Approved ancillary codes found at data.oregon.gov/Health-Human-Services/Group-6060-Ancillary-Services/fq2m-i6ix/about_data.

(b) Providers may consult the:

(A) Oregon Medicaid Dental Services billing code supplemental reference at https://data.oregon.gov/Health-Human-Services/Oregon-Medicaid-Dental-Services/495m-gmu2/about_data as a tool to assist with billing for services. Use of this supplemental reference is for guidance purposes only and must not serve as the sole basis for authorization or denial of services; and

(B) Medical-Dental Fee Schedule found on the OHP Fee-for-Service Fee Schedule site found at www.oregon.gov/oha/hsd/ohp/pages/fee-schedule.aspx.

(3) The providers rendering services and receiving payment for any of the services identified in these Chapter 410, Division 123, rules must make records available for audit, as required by OAR 410-123-1620.

(4) All Oregon Administrative Rules (OARs), Medicaid covered services, in Chapter 410 must be followed.

(5) All coverage limitations and exclusions are subject to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) review as required by Chapter 410, Division 151.

(6) Covered dental and oral health services provided in non-dental settings including medical, community and school settings by providers who are medical providers such as physicians and nurses. Criteria and limitations are as follows:

(a) Dental Screening of a patient (D0190) – including state or federally mandated screenings, are limited observations performed as mass screenings or EPSDT well-child and preventative care visits, to identify individuals who have suspected oral health needs and who must be seen by a dentist for diagnosis. Providers must hold a certificate of completion of the Smiles for Life or First Tooth training; and

(b) Dental Assessments (D0191) – are limited clinical inspections performed to identify possible signs of oral systemic disease, malformation, or injury, and the potential need for referral diagnosis and treatment. Providers must hold a certificate of completion of the Smile for Life or First Tooth training;

(c) Application of topical fluoride (99128, 99188, D1206, D1208), requires providers to hold a certificate of completion of the Smiles for Life or First Tooth training;

(A) The application of topical fluoride may be delegated by providers to staff, in accordance to their professional boards’ scope of practice;

(B) For EPSDT beneficiaries – limited to twice (2) every 12 months;

(D) Additional applications may be available, up to a total of four (4) per member within a 12 month period, when high-risk conditions or dental health factors are clearly documented in chart notes for members who:

(i) Have high-risk dental conditions due to disease process, medications, other medical treatments or conditions, or rampant caries;

(ii) Are pregnant or 12 months postpartum;

(iii) Have physical disabilities and cannot perform adequate daily dental health care;

(iv) Have developmental disabilities or other severe cognitive impairment and cannot perform adequate daily dental health care; or

(v) Are under seven (7) years old with high-risk dental health factors, such as poor dental hygiene, deep pits and fissures in teeth, severely crowded teeth, poor diet, etc.

(d) Application of silver diamine fluoride (0792T) by a physician or other healthcare professional is a covered benefit when the member has non-cavitated caries. Providers must hold a certificate of completion of the Smiles for Life or First Tooth training;

(A) For all members – limited to two (2) applications per 12 months; and

(B) Documentation of need must be included on submitted claims.

(7) Diagnostic services (CDT codes D0100 – D0999):

(a) Dental screenings (D0190) and dental assessments (D0191) do not take the place of the need for comprehensive dental evaluations and exams;

(A) For EPSDT beneficiaries – a maximum of twice (2) every 12 months;

(B) For non-EPSDT beneficiaries – a maximum of once (1) every 12 months;

(C) Reimbursable only if an exam (D0120-D0180) is not performed on the same date of service at the same place of service;

(D) The assessment tool used for D0190 and D0191 must be endorsed by the American Dental Association, the American Academy of Pediatric Dentistry, the Association of State and Territorial Dental Directors, or the American Academy of Pediatrics;

(E) Referrals for identified dental needs or for the establishment of a dental home are to be made to the member’s primary care dentist for FFS members, or to the member’s CCO (or dental subcontractor); and

(F) Anticipatory guidance and counseling on good dental hygiene practices and nutrition is to be provided to the member’s caregiver.

(b) The Authority requires dental subcontractors and dental providers to conduct an intake screening of individuals who are enrolled in the Veterans Dental Program within 60 days of the enrolled individual contacting the dental subcontractor or dental provider. This intake screening requires one of the following services being provided, as clinically appropriate:

(A) D0150 – comprehensive oral evaluation of a new or established patient;

(B) D0180 – comprehensive periodontal evaluation of a new or established patient; or

(C) D0120 – periodic oral evaluation of an established patient, if the individual enrolled in the Veterans Dental Program is an established patient.

(c) Caries risk assessment and documentation (D0601, D0602, D0603) are not separately reimbursable but should be documented in the member’s chart.

(d) Referrals:

(A) If, during the screening process (periodic or inter-periodic), a dental, medical, substance abuse, or medical condition is discovered, the member must be referred to an appropriate provider for further diagnosis and/or treatment;

(B) The screening provider must explain the need for the referral to the member, member's parent, or guardian;

(C) If the member, member's parent, or guardian agrees to the referral, assistance in finding an appropriate provider and making an appointment shall be offered; and

(D) The member’s FFS provider or the CCO shall make available care coordination as needed.

(e) Clinical Dental evaluations (Exams) for:

(A) EPSDT beneficiaries (refer to Division 151):

(i) The Authority covers exams (D0120, D0145, D0150, or D0180) a maximum of twice (2) every 12 months. These codes are not billable if D0191 is billed for the same date of service, at the same place of service. Limitations are as follows:

(I) D0150: once (1) every 12 months when performed by the same practitioner;

(II) D0180: once (1) every 12 months; and

(ii) The Authority must reimburse D0160 only once (1) every 12 months when performed by the same practitioner.

(B) Non-EPSDT beneficiaries, the Authority covers exams (D0120, D0150, D0160, or D0180) once (1) every 12 months;

(C) For problem-focused exams (urgent or emergent problems), the Authority covers D0140 for the initial exam and D0170 for related problem-focused follow-up exams. D0140 and D0170 are not covered for routine dental visits;

(D) The Authority only covers dental exams performed by medical practitioners when the medical practitioner is an oral surgeon. The surgeon may hold a dual degree, but must bill as an oral surgeon;

(E) The evaluation, diagnosis, and treatment planning components of the exam are the responsibility of the licensed provider. The Authority may not reimburse dental exams when performed by a dental hygienist (with or without an expanded practice permit).

(f) The Authority covers diagnostic imaging as follows:

(A) Intraoral – complete series (D0210) – One (1) time every five (5) years, unless D0330 has been billed within the five (5) year period;

(B) Intraoral – first image (D0220) – One (1) time every 12 months;

(C) Intraoral – additional images (D0230) – Under age six (6), maximum of five (5) times every 12 months. Not to exceed five (5) times on the same date of service for any provider. Radiographs may be billed separately one (1) time every 12 months;

(D) Intraoral – occlusal image (D0240) – One (1) time every 12 months. Not to exceed four (4) times on the same date of services for any provider;

(E) Extraoral images (D0250 and D0251) – One (1) time every 12 months;

(F) Bitewing single image (D0270) – Maximum of two (2) times every 12 months if not billing D0272;

(G) Bitewing two images (D0272) – Under age six (6), maximum of one (1) time every 12 months if not billing D0270 twice;

(H) Bitewing, multiple images (D0273, D0274 and D0277) – One (1) time every 12 months;

(I) Other TMJ images (D0321) – By Report;

(J) Dental tomographic survey (D0322) – One (1) time every 12 months;

(K) Panoramic image (D0330) – One (1) time every five (5) years, unless D0210 has been billed within the five (5) year period;

(L) Cone beam CT capture (D0364, D0365, D0366, D0367) – Only when performed as part of the pre-orthodontic treatment examination; and

(M) 3d print of 3d surface scan (D0396).

(g) The Authority covers panoramic radiographic image (D0330) or intra-oral complete series (D0210) once (1) every five (5) years, but both cannot be done within the five (5) year period;

(h) Members must be a minimum of six (6) years old for billing intra-oral complete series. The minimum standards for reimbursement of intra-oral complete series are:

(A) For members age six (6) through 11 a minimum of 10 periapical and two (2) bitewings for a total of 12 films; and

(B) For members ages 12 and older a minimum of 10 periapical and four (4) bitewings for a total of 14 films.

(i) If fees for multiple single radiographs exceed the allowable reimbursement for an intraoral-complete series (full mouth), the Authority must reimburse for the complete series;

(j) Additional films are covered if medically necessary and dentally appropriate (e.g., fractures);

(k) If the Authority determines the number of radiographs to be excessive, payment for some or all radiographs of the same tooth or area shall be denied;

(l) The exception to these limitations is if the member is new to the office or clinic and the office or clinic is unsuccessful in obtaining radiographs from the previous dental office or clinic. Supporting documentation outlining the provider's attempts to receive previous records must be included in the member's records; and

(m) Digital radiographs, if printed, must be on photo paper to assure sufficient diagnostic quality of images.

(8) Preventative Services (CDT codes D1000-D1999):

(a) Topical application of fluoride (D1206, D1208, 99128, 99188):

(A) For EPSDT beneficiaries, limited to twice (2) every 12 months;

(B) For non-EPSDT beneficiaries, limited to once (1) every 12 months;

(C) Additional topical fluoride treatments are available, up to a total of four (4) treatments per member within a 12 month period, when high-risk conditions or dental health factors are clearly documented by D0603 in chart notes for members who:

(i) Have high-risk dental conditions due to disease process, medications, other medical treatments or conditions, or rampant caries;

(ii) Are pregnant or 12 months postpartum;

(iii) Have physical disabilities and cannot perform adequate daily dental health care;

(iv) Have developmental disabilities or other severe cognitive impairment and cannot perform adequate daily dental health care; or

(v) Are under seven (7) years old with high-risk dental health factors, such as poor dental hygiene, deep pits, and fissures in teeth, severely crowded teeth, poor diet, etc.

(D) Fluoride limits include any combination of fluoride varnish or other topical fluoride.

(b) Dental sealants (D1351) are covered for EPSDT beneficiaries as follows:

(A) Members age 16 and older require PA;

(B) Only permanent molars (additional teeth require PA);

(D) The original provider is responsible for any repair or replacement during the 36-month period of initial sealant placement.

(c) Dental prophylaxis (D1110, D1120) are not covered by the Authority if provided on the same date of service as D4355, D4346 or D4910. Coverage is as follows:

(A) EPSDT beneficiaries, limited to twice (2) per 12 months;

(B) Non-EPSDT beneficiaries, limited to once (1) per 12 months; and

(C) Additional prophylaxis benefit provisions are available for persons with high-risk dental conditions due to disease process, pregnancy, medications, or other medical treatments or conditions, severe periodontal disease, rampant caries and for persons with disabilities who cannot perform adequate daily dental health care.

(d) Silver diamine fluoride (SDF) application (D1354, D1355):

(A) Is covered for all members;

(B) The Authority reimburses per application, not per tooth;

(C) Is limited to two (2) applications per year. Additional applications for EPSDT beneficiaries is allowable with approved PA;

(D) Requires that the tooth or teeth numbers be included on the claim;

(E) Use D1354 when SDF is applied for the treatment (rather than prevention) of caries. The treated tooth or teeth must be;

(i) Covered with topical application of fluoride; or

(ii) Covered with an interim direct restoration (D2940) or a permanent restoration when medically necessary and dentally appropriate.

(F) When SDF is applied for the treatment of caries by a non-dental professional (0792T), refer to the guidance in the earlier section of this rule. Coverage is limited to two (2) applications per year.

(e) Immunization counseling (D1301) is covered as described in 410-123-1262.

(f) The Authority covers Tobacco counseling for the control and prevention of oral disease (D1320) for services provided during a dental visit, when using the Five-A approach outlined below, limited to a maximum of 10 services within a three (3) month period, when the following is provided:

(A) ASK: Identify the member’s tobacco-use status at each visit and record information in the chart;

(B) ADVISE: Using a strong personalized message, advise members on their dental health conditions related to tobacco use and give direct advice to quit using tobacco and seek help;

(C) ASSESS: Refer member to external resources or internal counseling and intervention protocol if the tobacco user is willing to make a quit attempt;

(D) ASSIST: Provide counseling and pharmacotherapy to help member quit tobacco, if dental provider chooses to assist; and

(E) ARRANGE: Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date if dental provider chooses to arrange.

(g) The Authority covers Nutritional counseling (D1310) and Counseling for high risk substance use (D1321) for services provided during a dental visit using the Five-A approach outlined below. Each of these services is limited to two (2) services within a 12 month period, when the following is provided:

(A) ASK: Identify the member’s behavior;

(B) ADVISE: Urge the member to change behavior;

(D) ASSIST: Help the member with a plan and resources, if dental provider chooses; and

(E) ARRANGE: Schedule follow-up support, if dental provider chooses.

(h) Space maintenance (passive appliances) are:

(A) Covered for EPSDT beneficiaries; and

(B) Not replaceable when lost or damaged.

(9) The Authority’s coverage limitations of restorative, periodontic, and prosthetic treatments include the following:

(a) Documentation must be included in the member’s charts to support the treatment;

(b) Treatments must be consistent with the prevailing standard of care and may be limited as follows, when:

(A) Prognosis is unfavorable;

(B) Treatment is impractical;

(D) The treatment has specific limitations outlines in this rule.

(c) Periodontal health needs to be stable and supportive of a prosthetic. Prosthetic treatment, including porcelain fused to metal crowns and porcelain/ceramic crowns are limited until documented by examination;

(A) Rampant caries is arrested; and

(B) A period of adequate dental hygiene and periodontal stability is demonstrated.

(10) Restorative Services (CDT codes D2000-D2999):

(a) Amalgam and resin-based composite restorations, direct:

(A) Resin-based composite crowns on anterior teeth (D2390) are only covered for EPSDT beneficiaries, and members who are pregnant;

(B) The Authority reimburses posterior composite restorations at the same rate as amalgam restorations;

(D) The Authority limits payment of covered restorations to the maximum restoration fee of four (4) surfaces per tooth. Refer to the ADA CDT codebook for definitions of restorative procedures;

(E) Providers must combine and bill multiple surface restorations as one line per tooth using the appropriate code. Providers may not bill multiple surface restorations performed on a single tooth on the same day on separate lines. For example, if tooth #30 has a buccal amalgam and a mesial-occlusal-distal (MOD) amalgam, then bill MOD, B, using code D2161 (four (4) or more surfaces);

(F) The Authority shall not reimburse for an amalgam or composite restoration and a crown on the same tooth;

(G) Interim direct restorations (D2940) on primary dentition are covered to restore and prevent progression of dental caries. They are not definitive restorations and are not to be used as a base or liner under a restoration;

(H) Reattachment of tooth fragment is covered once in the lifetime of a tooth when there is no pulp exposure and no need for endodontic treatment;

(I) The Authority reimburses for a surface not more than once (1) in each treatment episode regardless of the number or combination of restorations; and

(J) The restoration fee includes payment for occlusal adjustment and polishing of the restoration.

(b) Indirect crowns and related services:

(A) The fee for the crown includes payment for preparation of the gingival tissue;

(B) The Authority covers crowns only when there is significant loss of clinical crown, no other restorations restore function, the crown-to-root ratio is 50:50 or better, and the tooth is restorable to function without other surgical procedures. Endodontic therapy alone (with or without a post) is not a consideration, nor are aesthetics;

(i) Necessary to retain a cast restoration due to extensive loss of tooth structure from caries or a fracture;

(ii) Done in conjunction with a crown; and

(iii) More than 50 percent of the tooth structure is remaining for coverage of the core buildup.

(D) Reimbursement of retention pins is per tooth, not per pin;

(E) Payment shall be made only upon final cementation;

(F) Partial payment will not be made for an undelivered crown;

(G) Prefabricated stainless steel crowns are allowed only for anterior primary teeth and posterior permanent or primary teeth;

(H) The Authority covers the following only for EPSDT beneficiaries, and for members who are pregnant:

(i) Prefabricated resin crowns for anterior teeth, permanent or primary;

(ii) Prefabricated resin crowns for posterior teeth, permanent or primary, once (1) per tooth in a five (5) year period;

(iii) Prefabricated stainless-steel crowns with resin window are allowed only for anterior teeth, permanent or primary;

(iv) Prefabricated post and core in addition to crowns;

(v) Crowns (resin-based composite — D2710 and D2712, porcelain fused to metal (PFM) — D2751 and D2752, and porcelain ceramic – D2740 as follows:

(I) Limited to teeth numbers 6–11, 22, and 27 only, if dentally appropriate;

(II) Limited to four (4) in a seven (7) year period. This limitation includes any replacement crowns allowed; and

(III) Rampant caries are arrested, and the member demonstrates a period of adequate dental hygiene before prosthetics are proposed.

(vi) Porcelain fused to metal crowns (D2751, D2752), and porcelain ceramic crowns (D2740) must meet the following additional criteria:

(I) The Dental Practitioner has attempted all other dentally appropriate restoration options and documented failure of those options;

(II) Written documentation in the member’s chart indicates that PFM is the only restoration option that restores function;

(III) The Dental Practitioner submits radiographs to the Authority for review. History, diagnosis, and treatment plan may be requested;

(IV) The member has documented stable periodontal status with clinical attachment loss within 1–3 millimeters. If PFM crowns are placed with pocket depths of 4 millimeters and over, documentation must be maintained in the member’s chart of the dentist’s findings supporting stability and why the increased pocket depths shall not adversely affect expected long-term prognosis;

(V) The crown has a favorable long-term prognosis; and

(VI) If the tooth to be crowned is a clasp/abutment tooth in partial denture, both prognosis for the crown itself and the tooth’s contribution to partial denture must have favorable expected long-term prognosis.

(I) Crown replacement coverage is as follows:

(i) D2710, D2712, D2740, D2751, D2752 are limited to once (1) every seven (7) years;

(ii) All other covered crowns are limited to once (1) every five (5) years; and

(iii) Exceptions to the above limitations due to acute trauma are based on the following factors:

(I) Extent of crown damage;

(II) Extent of damage to other teeth or crowns;

(III) Extent of impaired mastication;

(IV) Tooth is restorable without other surgical procedures; and

(V) If loss of tooth may result in coverage of removable prosthetic.

(J) Crown repair requires PA and is limited to anterior teeth.

(11) Endodontic Services (CDT codes D3000-D3999):

(a) All radiographic images taken during the course of root canal therapy and all post-treatment radiographic images are included in the fee for the root canal procedure. At least one (1) pre-treatment radiographic image demonstrating the need for the procedure, and one (1) post-treatment radiographic images that demonstrates the result of the treatment, must be maintained in the member’s record;

(b) The Authority covers endodontic therapy as follows only when the crown-to-root ration is 50:50 or better and if the tooth is restorable to function with direct or indirect restoration without other surgical procedures:

(A) For EPSDT beneficiaries: all primary teeth, permanent anterior teeth, premolars, first molars and second molars;

(B) For members who are pregnant or 12 months postpartum: permanent anterior teeth, premolars, and first molars; and

(A) The Authority does not cover retreatment of a previous root canal or apicoectomy for premolars or molars;

(B) The Authority limits either a retreatment or an apicoectomy (but not both procedures for the same tooth) to symptomatic anterior teeth when:

(i) Crown-to-root ratio is 50:50 or better;

(ii) The tooth is restorable without other surgical procedures; or

(iii) If loss of tooth shall result in the need for removable prosthodontics.

(d) The Authority does not allow separate reimbursement for open-and-drain as a palliative procedure when the root canal is completed on the same date of service or if the same practitioner or Dental Practitioner in the same group practice completed the procedure;

(e) Apexification/recalcification procedures:

(A) The Authority limits payment for apexification to permanent teeth only;

(B) D3351-D3353 are limited to once (1) per tooth; and

(12) Periodontic Services (CDT codes D4000-D4999):

(a) The Authority does not reimburse the following codes if performed on the same date of service D1110, D1120, D4210, D4211, D4341, D4346, D4355, and D4910.

(b) Surgical periodontal services:

(A) Gingivectomy/Gingivoplasty (D4210, D4211) coverage is limited to severe gingival hyperplasia where enlargement of gum tissue occurs that prevents access to dental hygiene procedures (e.g., Dilantin hyperplasia), and includes six (6) months routine postoperative care; and

(B) Gingivectomy or gingivoplasty to allow for access for restorative procedure, per tooth (D4212) is considered part of the restoration and is not separately billable.

(A) Periodontal scaling and root planing (D4341, D4342) is allowed once (1) every two (2) years;

(i) A maximum of two (2) quadrants on one date of service is payable, except in extraordinary circumstances supported by documentation;

(ii) Quadrants are not limited to physical area, but are further defined by the number of teeth with pockets of 5 mm or greater:

(B) Single implants may count as an additional tooth when billing, the maximum number per quadrant and pocket depth requirements still apply;

(D) Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth, after dental evaluation (D4346) is allowed once (1) every two (2) years.

(d) Periodontal maintenance (D4910) is allowed once (1) every six (6) months:

(A) Following periodontal therapy (surgical or non-surgical) that is documented to have occurred within the past three (3) years; and

(B) Additional periodontal maintenance requires PA and may be requested when:

(i) Medically necessary and dentally appropriate, including situations involving periodontal disease during pregnancy; and

(ii) The member’s medical record is submitted and supports the need for increased periodontal maintenance (chart notes, pocket depths and radiographs).

(e) Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth charting and radiographs;

(13) Prosthodontics, Removable (CDT codes D5000-D5899):

(a) The Authority covers complete dentures once (1) every 10 years, only if medically necessary and dentally appropriate, with PA approval;

(A) Coverage is for only one of the following options (not both);

(i) Complete dentures (D5110, D5120); or

(ii) Immediate dentures (D5130, D5140);

(B) The Authority’s 10-year coverage limitation for complete dentures applies regardless of the member’s OHP or CCO enrollment status at the time the member received the denture; and

(b) The fee for the denture includes payment for adjustments during the six (6) month period following the delivery of the denture. Adjustments and repairs needed beyond six (6) months from the delivery of the denture are covered by the Authority as follows:

(A) A maximum of four (4) times per year for:

(i) Adjustments to dentures, per arch (D5410, D5411);

(ii) Replacement of missing or broken teeth, each tooth (D5520); and

(B) A maximum of two (2) times per year for broken complete denture base (D5511, D5512).

(c) The Authority covers partial dentures once (1) every five (5) years, only if medically necessary and dentally appropriate, with PA approval;

(A) Coverage is for only one of the following options:

(i) Partial denture resin base (D5211, D5212);

(ii) Immediate partial denture (D5221, D5222) or

(iii) Interim partial dentures (D5820, D5821);

(B) The Authority’s five (5) year coverage limitation for partial dentures applies regardless of the member’s OHP or CCO enrollment status at the time the member’s last partial was received;

(D) Interim partial dentures (also referred to as “flippers”) are covered only if the member has one (1) or more anterior teeth missing;

(E) Partial dentures and immediate partial dentures are covered as follows:

(i) For EPSDT members: The member must have one (1) or more anterior teeth missing or four (4) or more missing posterior teeth per arch with resulting space equivalent to the loss demonstrating inability to masticate. Third molars are not a consideration when counting missing teeth;

(ii) For non-EPSDT members: The member must have one (1) or more missing anterior teeth or six (6) or more missing posterior teeth per arch with documentation by the provider of resulting space causing serious impairment to mastication. Third molars are not a consideration when counting missing teeth;

(F) The Practitioner must note the teeth to be replaced and the teeth to be clasped with requesting PA;

(G) The Authority does not approve resin partial dentures (D5211, D5212) if stainless steel crowns are used as abutments; and

(H) Partial dentures are not to be used in lieu of space maintainers.

(d) The fee for the partial denture includes payment for adjustments during the six (6) month period following delivery. Adjustments and repairs needed beyond six (6) months after delivery of the partial denture as follows:

(A) A maximum of four (4) times per year for:

(i) Adjustments to partial dentures, per arch (D5421, D5422)

(ii) Replace broken tooth on a partial denture, each tooth (D5640)

(iii) Add tooth to existing partial denture (D5650);

(B) A maximum of two (2) times per year for:

(i) Repair resin partial denture base (D5611, D5612);

(ii) Repair cast partial framework (D5621, D5622);

(iii) Repair or replace broken retentive/clasping materials, per tooth (D5630); and

(iv) Add clasp to existing partial denture, per tooth (D5660);

(i) A maximum of once (1) per five (5) years per arch;

(ii) When five (5) or more years have passed since the partial denture was originally delivered; and

(iii) Is considered replacement of the partial denture so a new denture shall not be reimbursed for another five (5) years.

(e) For denture reimbursement;

(A) The member must have active coverage on the date of the final impression;

(B) The dentures must be delivered within 45 days of the date of the final impression; and

(C) The claim includes both the date of the final impression and the date of delivery. If the member loses OHP coverage during the time that the denture is being fabricated, submit the claim using the date of the final impression.

(f) The Authority may cover reasonable and necessary replacement of medically necessary and dentally appropriate covered dentures, including those purchased or in used before the member enrolled with OHP;

(g) Replacement of dentures is covered involving the provision of the medically necessary and dentally appropriate item when:

(A) The item cannot be made clinically serviceable by a less costly procedure (e.g., reline, rebase, repair, tooth replacement);

(B) The loss of the item is due to circumstance beyond the member’s control (e.g., irreparable damage referring to a specific accident, natural disaster, or situation);

(C) There is a change in the member’s condition that warrants a new item (e.g., cases of acute trauma, catastrophic illness that directly or indirectly affects the dental condition and results in additional tooth loss). This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical, and medical treatment for conditions mentioned earlier; and

(D) There is coverage for the specific item as identified in Chapter 410, Division 123.

(h) The Authority may not cover replacement of dentures:

(A) When cases suggest malicious damage, culpable neglect, or wrongful disposition of the denture; or

(B) In the presence of untreated severe periodontal disease.

(i) Replacement of a partial denture with a complete denture is payable five (5) years after the partial denture placement;

(j) The Authority covers denture rebase procedures (D5710, D5711, D5720, D5721) as follows, only if a reline does not adequately solve the problem:

(A) For EPSDT members: once (1) every three (3) years;

(B) For non-EPSDT members: once (1) every five (5) years when there is documentation of a current, failed reline procedure;

(C) Exceptions to these limitations may be considered by the Authority for conditions as listed for warranting replacement of partial and complete dentures; and

(D) Untreated severe periodontal disease may not warrant rebase procedures.

(k) The Authority covers denture reline (direct) procedures (D5730, D5731, D5740, D5741) as follows:

(A) For EPSDT members: once (1) every three (3) years;

(B) For non-EPSDT members: once (1) every five (5) years;

(C) A new or replacement complete or partial denture(s) on the same arch are not reimbursable for 12 months after the reline; and

(D) Exceptions to these limitations may be considered by the Authority for conditions as listed for warranting replacement of partial and complete dentures.

(l) The Authority covers denture reline (indirect) laboratory procedures (D5750, D5751, D5760, D5761) six (6) months after placement of any denture as follows:

(A) For EPSDT members: once (1) every three (3) years;

(B) For non-EPSDT members: once (1) every five (5) years;

(D) Exceptions to these limitations may be considered by the Authority for conditions as listed for warranting replacement of partial and complete dentures.

(m) The Authority covers tissue conditioning (D5850, D5851) for all members once:

(A) Per denture unit in conjunction with immediate dentures; and

(B) Prior to new denture placement.

(14) Maxillofacial Prosthetic Services (CDT codes D5900-D5999):

(a) Fluoride gel carrier is limited to those members whose severity of dental disease causes the increased cleaning and fluoride treatments allowed in rule to be insufficient. The Dental Practitioner must document failure of those options prior to use of the fluoride gel carrier; and

(b) All other maxillofacial prosthetics are medical services;

(A) Bill for medical maxillofacial prosthetics using the professional (CMS1500, DMAP 505, 837D or 837P) claim format;

(B) For members receiving services through a CCO, bill medical maxillofacial prosthetics to the CCO; and

(15) Prosthodontics, Fixed (CDT codes D6200-D6999): Surgical removal of implant body (D6100) and Removal of implant body (D6105) are covered for all members, per Guideline Note 123, when there is:

(a) Advanced peri-implantitis with bone loss and mobility, abscess; or

(b) Implant fracture.

(16) Oral & Maxillofacial Surgery (D7000-D7999): Billing Procedures:

(a) Bill on a dental claim form using CDT codes for procedures that are directly related to the teeth and the structures directly supporting teeth;

(b) The Medical/Surgical Program is responsible for all dental health procedures performed due to an underlying medical condition (i.e., procedures on or in preparation for treatment of the jaw, tongue, roof of mouth). Such procedures must be billed using ICD-10, HCPCS and CPT billing codes using the professional (CMS1500, DMAP 505 or 837P) claim format;

(c) The following services are covered based on severity and included situations deemed to cause gingival recession or movement of the gingival margin when frenum is placed under tension:

(A) Buccal/labial frenectomy (frenulectomy) (D7961), refer to Guideline Note 48;

(i) Maxillary labial frenulectomy is not covered until age 12; and

(ii) Not billable if member has received D7963;

(B) Lingual frenectomy (frenulectomy) (D7962), refer to Guideline Note 48 and 139, is not covered until age 12 unless ankyloglossia is interfering with breastfeeding; or

(i) Once (1) per lifetime per quadrant; and

(ii) Not billable if member has received D7961.

(d) Emergency tracheotomy (D7990) is an ancillary code reimbursable for all members;

(e) All ancillary and diagnosis codes must be used for services that are medically necessary and dentally appropriate; and

(f) Alveoloplasty not in conjunction with extractions (D7320, D7321) is reimbursable for EPSDT beneficiaries, and for members who are pregnant or 12 months postpartum.

(17) Orthodontics (CDT Codes D8000-D8999):

(a) The Authority covers orthodontia services and extractions to treat cleft palate with airway obstruction, cleft palate and/or cleft lip, or deformities of the head, and handicapping malocclusions (HM), not for cosmetic purposes, when:

(A) The member has a craniofacial anomaly health condition that is included on a covered line of the Prioritized List of Health Services;

(B) The Authority approves the PA request for orthodontic treatment: and

(i) Dental Appropriateness as demonstrated when the member has a malocclusion; and

(ii) Medical Necessity for the orthodontic treatment is demonstrated when the member meets the automatic qualifying criteria and/or a score of 26 or higher on the Handicapping Labiolingual Deviation (HLD) score index.

(b) Pre-orthodontic treatment examinations (D8660) must be provided by a licensed dentist.

(c) Pre-orthodontic treatment examinations (D8660) do not require PA. Coverage is for members whose clinical presentation and preliminary comprehensive or periodic exam findings strongly suggest that they may qualify for orthodontic treatment under HM criteria, as established by the Authority. The imaging required for evaluation is not to be billed separately. Coverage is:

(A) Once (1) per member, per provider, in a 12 month period (not on the same day as another routine or general dental evaluation or examination); and

(B) When submitted alongside the following documentation to justify the need for treatment:

(i) The Authority-approved HLD Index California Modified Scoring Form (completed, scored, and signed);

(ii) Intra-oral and extra-oral photographs of diagnostic quality, adhering to American Association of Orthodontists (AAO) standards, capturing key aspects of the malocclusion;

(iii) Panoramic radiographs or cephalometric images including tracings that document skeletal and dental relationships crucial for evaluating the severity of malocclusion; and

(iv) A comprehensive narrative of medical necessity, explicitly stating how the malocclusion significantly impacts the member's oral health, airway, or overall functional capacity.

(d) PA approval for comprehensive orthodontic treatment (D8070, D8080, D8090, D8091), must meet the criteria in Guideline Note 169 of the Prioritized List of Health Service.

(e) Comprehensive orthodontic treatment must be completed by a licensed dentist who has:

(A) Completed a Commission of Dental Accreditation (CODA) orthodontic fellowship or residency program;

(B) Certified additional orthodontic training, a minimum of 30 hours of orthodontic continuing education (CE) in the past three (3) years that was approved by the American Dental Association Continuing Education Recognition Program (ADA CERP); or

(C) Completed five (5) comprehensive orthodontic treatment cases in the past three (3) years, verified by case logs and patient outcomes.

(f) Orthodontic treatment must begin while the member is an EPSDT beneficiary, or immediately after, if surgical corrections that were started during the member’s EPSDT beneficiary period for covered conditions were not completed during that period.

(g) Payment for comprehensive orthodontic treatment includes all appliances, repairs, and all follow-up visits.

(h) The Authority pays for orthodontia in one (1) lump sum upon beginning of treatment;

(A) If the member transfers to another orthodontist during treatment, or treatment is terminated, the Authority shall recover the overpayment (refer to OAR 410-120-1397) based on the length of the treatment plan from the first date of service (DOS); and

(B) Providers may discontinue orthodontic treatment of a member in cases including poor dental hygiene, continued missed appointments, or if treatment is a detriment to the member.

(i) Licensed dentists providing orthodontic treatment may:

(A) Submit PA requests for the extractions and/or bond surgeries that are documented as needed in the member’s orthodontic treatment plan; and

(B) Refer members to enrolled specialists for extractions and/or bond surgeries when such services are beyond the scope of the member’s primary care dentist.

(j) As long as the orthodontist continues treatment, the Authority may not require a refund even though the member may become ineligible for medical assistance sometime during the treatment period.

(k) Care navigation assistance for members must be made available during transfer of care in situations such as provider changes.

(18) Adjunctive General and Other Services (CDT codes D9000-D9999):

(a) Fixed partial denture sectioning (D9120) is covered only when extracting a tooth connected to a fixed prosthesis and a portion of the fixed prosthesis is to remain intact and serviceable, preventing the need for more costly treatment;

(b) Anesthesia and sedation:

(A) The Authority reimburses administration of general anesthesia or IV sedation only for those members with concurrent needs: age; physical, medical, or mental status; or degree of difficulty of the procedure; and

(B) The Authority reimburses providers with a current permit to administer General Anesthesia or IV Sedation as follows:

(i) For each 15-minute period, up to two and a half hours on the same day of service in a dental office setting, and up to three and a half hours on the same day of service in a hospital setting and ASC;

(ii) Each 15-minute period represents a quantity of one (1). Enter this number in the quantity column.

(D) Enteral and Non-intravenous parenteral conscious sedation with or without coadministration of Nitrous Oxide are covered only for EPSDT beneficiaries as follows:

(i) Members age 13 and older require PA;

(ii) Limited to four (4) times per year; and

(iii) Includes payment for monitoring and Nitrous Oxide;

(E) Upon request, providers must submit a copy of their permit to administer Anesthesia, Analgesia, and Sedation to the Authority; and

(F) The Authority covers CPT 00170 (anesthesia services during procedures on the mouth). When billing for services provided in conjunction with dental treatments in the office setting, use the professional claim format using an appropriate non-facility Place of Service code.

(c) House/extended care facility call (D9410) is limited to urgent or emergent dental visits that occur outside of a dental office. This code is not reimbursable for provision of preventive services or for services provided outside of the office for the provider’s or facility’s convenience.

(19) Sleep Apnea Services:

(a) Sleep apnea devices and appliances may be placed or fabricated by a general dentist or specialist although they are considered medical services;

(b) Bill for sleep apnea services using medical billing codes on the professional claim form unless guidance specifies otherwise;

(c) Custom sleep apnea appliance fabrication and placement (D9947) must be billed on a dental claim form (see HERC Guideline Notes 27 and 36 for criteria), and is replaceable at the end of the five (5) year reasonable useful lifetime;

(d) The Authority does not cover adjustments for dental sleep apnea appliances. The adjustments are considered part of the normal follow-up care within the first 90 days after provision of the device, and are included as services of (D9947); and

(e) Dental sleep apnea repairs (D9949) are covered when necessary and appropriate to make item serviceable. If the expense for repairs exceeds the estimated expense of purchasing another item, no payment must be made for the excess.

(20) Dental care access standards for pregnant members:

(a) Dental care benefits for pregnant members shall continue for 12 months following the end of pregnancy; and

(b) For additional dental care benefit for members who are pregnant or 12 months postpartum, refer to OAR 410-123-1510.

(21) Services considered incidental, integral to the primary service rendered, part of another service, or included in routine post-op or follow-up care are not eligible for separate reimbursement.

(a) Participating providers may not balance bill members for these services;

(b) Not all services included in the Current Dental Terminology (CDT) codebook are covered by the Authority;

(d) Under the Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) issued regulations in 2024 for payment for dental services that are inextricably linked to certain covered medical services, such as dental exams and necessary treatments prior to organ transplants, cardiac valve replacements, valvuloplasty procedures, and treatments for head and neck cancers. Such services should be billed directly to Medicare.

(22) The following services are not eligible for separate reimbursement:

(a) Alveolectomy/Alveoloplasty in conjunction with extractions;

(b) Cardiac and other monitoring;

(d) Curettage and root planing — per tooth is not eligible for separate reimbursement unless the service is significant and separately identifiable;

(e) Diagnostic casts (D0470);

(f) Direct pulp cap (D3110);

(g) Discing;

(h) Dressing change;

(i) Electrosurgery;

(j) Equilibration;

(k) Gingival curettage — per tooth (D4220);

(l) Gingival irrigation (D4921);

(m) Gingivectomy or gingivoplasty to allow for access for restorative procedure, per tooth (D4212);

(n) Indirect pulp cap (D3120);

(o) Local anesthesia;

(p) Medicated pulp chambers;

(q) Occlusal adjustments (D9951, D9952);

(r) Occlusal analysis;

(s) Odontoplasty;

(t) Oral hygiene instruction (D1330);

(u) Periodontal charting, probing;

(v) Post removal;

(w) Polishing fillings;

(x) Post extraction treatment for alveolaritis (dry socket treatment) if done by the provider of the extraction;

(y) Pulp vitality tests (D0460);

(z) Smooth broken tooth;

(aa) Special infection control procedures;

(bb) Surgical procedure for isolation of tooth with rubber dam (D3910);

(cc) Surgical splint (D5988);

(dd) Surgical stent (D5982);

(ee) Suture removal;

(ff) Testing for cracked tooth (D0461); and

(gg) Teledentistry (D9995, D9996).

(23) The following general categories of dental services are not covered for any member, unless coverage is specified or member is an EPSDT beneficiary and meets requirements of OAR Chapter 410, Division 151, as several of these services are considered elective or “cosmetic” in nature (i.e., done for the sake of appearance):

(a) Desensitization;

(b) Implant and implant services (See Prioritized List Guideline Notes 123 and 169);

(d) Orthodontic treatment;

(e) Overhang removal;

(f) Procedures, appliances, or restorations solely for aesthetic or cosmetic purposes;

(g) Temporomandibular joint (TMJ) dysfunction treatment; and

(h) Tooth bleaching.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 11-2026, temporary amend filed 03/27/2026, effective 03/27/2026 through 09/22/2026
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 70-2025, temporary amend filed 09/23/2025, effective 09/26/2025 through 03/24/2026
DMAP 9-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 64-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 79-2023, amend filed 09/26/2023, effective 10/01/2023
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 13-2022, amend filed 02/09/2022, effective 02/09/2022
DMAP 10-2022, minor correction filed 02/04/2022, effective 02/04/2022
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 61-2020, amend filed 12/11/2020, effective 01/01/2021
DMAP 120-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 98-2018, temporary amend filed 10/26/2018, effective 11/01/2018 through 04/29/2019
DMAP 42-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 25-2017, f. & cert. ef. 6-29-17
DMAP 71-2016(Temp), f. 12-28-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 45-2016, f. & cert. ef. 7-13-16
DMAP 36-2016, f. 6-30-16, cert. ef. 7-1-16
DMAP 5-2016(Temp), f. & cert. ef. 2-9-16 thru 6-28-16
DMAP 74-2015(Temp), f. 12-18-15, cert. ef. 1-1-16 thru 6-28-16
DMAP 65-2015, f. 11-3-15, cert. ef. 12-1-15
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 46-2015(Temp), f. 8-26-15, cert. ef. 10-1-15 thru 3-28-16
DMAP 28-2015, f. & cert. ef. 5-1-15
DMAP 7-2015(Temp), f. & cert. ef. 2-17-15 thru 8-15-15
DMAP 56-2014, f. 9-26-14, cert. ef. 10-1-14
DMAP 36-2014, f. & cert. ef. 6-27-14
DMAP 19-2014(Temp), f. 3-28-14, cert. ef. 4-1-14 thru 6-30-14
DMAP 10-2014(Temp), f. & cert. ef. 2-28-14 thru 8-27-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 68-2013, f. 12-5-13, cert. ef. 12-23-13
DMAP 28-2013(Temp), f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13
DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13
DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12
DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 17-2011, f. & cert. ef. 7-12-11
DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09
DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 18-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08
OMAP 12-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 55-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 65-2003, f. 9-10-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 48-2002, f. & cert. ef. 10-1-02
OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 23-1999, f. & cert. ef. 4-30-99
OMAP 28-1998, f. & cert. ef. 9-1-98
OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98
HR 20-1995, f. 9-29-95, cert. ef. 10-1-95
HR 3-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-123-1262 Vaccine Counseling and Administration

(1) Dental administration of vaccines must be carried out in compliance with Oregon Board of Dentistry OARs 818-012-0006 and 818-012-0007, OHA Medical/Surgical OAR 410-130-0255 and Vaccines for Children (VFC) – OHA Division 46, OARs 333-046-0110 through 333-046-0130.

(2) The Authority covers immunization counseling (D1301) when the vaccine is not administered on the same date of service.

(3) Provider must:

(a) Be registered with the ALERT Immunization Information System (IIS) at a minimum as a query user;

(b) Stay current with recommended immunization schedules by keeping up to date on immunization science and protocols and understand the risks, benefits, contraindications, and potential adverse effects of vaccines;

(d) Explain to members which immunizations are recommended based on the member’s age, medical history, and risk factors and discuss the benefits of vaccination in preventing serious diseases;

(e) Counsel with the member what signs and symptoms of potential adverse effects may be and on when medical attention may be needed, addressing questions and concerns;

(f) Provide information to the member about where to obtain the vaccine(s); and

(g) Refer the member to their primary care provider for administration of the vaccine.

(4) The Authority encourages providers to take continuing education courses related to immunizations and to regularly review the OHA Immunization Information for Dentists website for best practices, educational resources, and additional information at https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/VACCINESIMMUNIZATION/IMMUNIZATIONPROVIDERRESOURCES/Pages/Dentists.aspx.

(5) Requirements for vaccine administration:

(a) The licensed provider must have completed a course of training approved by the Oregon Board of Dentistry;

(b) Licensed provider must register in ALERT;

(d) The dentist must not delegate administration of vaccines to another person.

(6) Procedures for licensed providers administering vaccines:

(a) Must report to ALERT within 14 days of administration;

(A) Follow the Authority approved Model Immunization Protocols for immunization administration and treatment of severe adverse events following an administration. The Authority Model Immunization Protocols are located at: www.oregon.gov/oha/PH/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/Pages/provresources.aspx (see Vaccine Administration section);

(B) Maintain written policies and procedures for handling and disposal of used or contaminated equipment and supplies;

(C) If providing state or federal vaccines, report the vaccine eligibility code as specified by the Authority, to the ALERT system outlined in www.oregon.gov/oha/PH/PreventionWellness/VaccinesImmunization/alert/Pages/EnrollNewClinic.aspx;

(b) Report adverse events within 10 business days to the:

(A) Vaccine Adverse Events Reporting System (VAERS);

(B) Oregon Board of Dentistry; and

(i) Provide the member with a copy of vaccination administration documentation;

(ii) Direct the member toward resources containing more information;

(iii) Encourage the member to become a physician's patient of record for their other health needs; and

(iv) Document actions in the member's record.

(A) Provide Vaccine Information Statements (VIS) to the member or legal representative with each dose of vaccine covered by these forms;

(B) Document that the member or legal representative has read, or has had read to them, the information provided and that any questions are answered prior to the administration of the vaccine. The VIS provided must be the most current version; and

(i) Date;

(ii) Site of administration;

(iii) Brand name or NDC number or other acceptable standardized vaccine code set;

(iv) Dose, manufacturer, lot # (number), and expiration date of vaccine;

(v) Name and identifiable initials of administering dentist;

(vi) Address of office where vaccine was administered, unless automatically embedded in electronic report provided to the Authority ALERT Immunization System; and

(vii) Date of publication of the VIS; and Date the VIS was provided.

(7) Vaccines are billed using CPT codes on a Professional claim form (CMS 1500) found in the Professional Billing Instructions and the Medical-Surgical Services Provider Guide located at: www.oregon.gov/oha/HSD/OHP/Tools/Medical-Surgical%20Services%20Provider%20Guide.pdf. Coverage is as follows:

(a) EPSDT beneficiaries:

(A) VFC vaccines are administered only to children and adolescents through age 18 who meet VFC eligibility criteria;

(B) All vaccines for this age group and for conditions covered by the VFC program must be obtained through the VFC program; and

(C) The Authority does not reimburse providers for the administration or purchase of privately purchased vaccines if the vaccine may have been obtained through the VFC program.

(b) Non-EPSDT beneficiaries: Billing providers must use standard professional claim form billing procedures for adults and for any vaccine that is not part of the VFC program; and

(c) For information about the VFC program or to enroll as a VFC provider, contact the Public Health Immunization Program. The Oregon VFC program website is: www.oregon.gov/oha/PH/PREVENTIONWELLNESS/VACCINESIMMUNIZATION/IMMUNIZATIONPROVIDERRESOURCES/VFC/Pages/index.aspx.

(8) The Authority reimburses only for the administration, not the serum, of vaccines available for free through the VFC Program. Refer to the Current Oregon Immunization Program State-Supplied Vaccine Billing Codes table in the Immunization Billing Resources section for a list of vaccines provided through the VFC Program.

(9) To receive reimbursement for vaccine administration, VFC program providers must bill the Authority with appropriate coding;

(a) CPT code and the modifier SL; or

(b) CDT code.

(10) FFS providers may bill the Authority directly for vaccines provided to members. Providers may bill the plans directly, as appropriate to member plan enrollment, for the administration of VFC vaccines if the member is enrolled in a CCO. Medicaid and Children's Health Insurance Program (CHIP) are not considered the “payer of last resort” for administration of VFC vaccines.

History

Statutory/Other Authority: ORS 679.543, 414.065 & HB 2220 (2019 Regular Session)
Statutes/Other Implemented: ORS 414.065
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 65-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 52-2022, minor correction filed 04/27/2022, effective 04/27/2022
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 66-2019, adopt filed 12/26/2019, effective 01/01/2020

Or. Admin. R. 410-123-1265 Teledentistry

(1) Teledentistry can take multiple forms, both synchronous and asynchronous, including but not limited to:

(a) Live video, a two-way interaction between a member and dentist using audiovisual technology;

(b) Store and forward, an asynchronous transmission of recorded health information such as radiographs, photographs, video, digital impressions, or photomicrographs transmitted through a secure electronic communication system to a dentist, and it is reviewed at a later point in time by a dentist. The dentist at a distant site reviews the information without the member being present in real time;

(c) Remote member monitoring, where personal health and dental information is collected by dental care providers in one location then transmitted electronically to a dentist in a distant site location for use in care; and

(d) Mobile communication devices such as cell phones, tablet computers, or personal digital assistants that may support mobile dentistry, health care, public health practices, and education.

(2) A member receiving services through teledentistry must be notified of the right to receive interactive communication with the distant dentist and must receive an interactive communication with the distant dentist upon request;

(a) The member’s chart documentation must reflect notification of the right to interactive communication with the distant site dentist; and

(b) A member may request to have real time communication with the distant dentist at the time of the visit or within 30 days of the original visit.

(3) Providers must be licensed to practice dentistry and enrolled as a Medicaid provider as required by OAR 410-120-1260.

(4) All Dental Services rules, criteria, limits, and billing requirements apply to teledentistry services in the same manner as other services.

(5) Providers billing for covered teledentistry services must follow all telehealth requirements in OAR 410-120-1990, which include:

(a) Complying with Health Insurance Portability and Accountability Act (HIPAA) and Oregon Health Authority (OHA) Confidentiality and Privacy Rules and security protections for the patient in connection with the telemedicine communication and related records;

(b) Obtaining and maintaining technology used in the telehealth communication that is compliant with privacy and security standards;

(c) Ensuring policies and procedures are in place to prevent a breach in privacy or exposure of member health information or records (whether oral or recorded in any form or medium) to unauthorized individuals; and

(d) Maintaining clinical and financial documentation related to telehealth services as required in OAR 410-120-1360 and OAR 410-120-1990.

(6) General Billing Requirements:

(a) Unless authorized in OAR 410-120-1990, other types of telecommunications such as telephone calls, images transmitted via facsimile machines, and electronic mail are not covered;

(b) The dentist may bill for teledentistry on the same type of claim form as other types of procedures unless in conflict with the Dental Services rules; and

(c) As stated in ORS 679.543 and this rule, payment for dental services may not distinguish between services performed using teledentistry, real time, or store-and-forward and services performed in-person.

(7) Teledentistry billing requirements:

(a) The dentist who completes diagnosis and treatment planning and the oral evaluation also documents these services using the traditional Current Dental Terminology (CDT) codes;

(b) The originating site may bill a CDT code only if a separately identifiable service is performed within the scope of practice of the practitioner providing the service. The service must meet all criteria of the CDT code billed;

(c) The provider must report the teledentistry event using the teledentistry billing codes for synchronous (D9995) or asynchronous (D9996), as appropriate; and

(d) D9995 and D9996 are not eligible for separate reimbursement.

History

Statutory/Other Authority: ORS 679.543 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 66-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 61-2020, amend filed 12/11/2020, effective 01/01/2021
DMAP 119-2018, adopt filed 12/26/2018, effective 01/01/2019

Or. Admin. R. 410-123-1490 Hospital Dentistry

(1) The purpose of hospital dentistry is to provide safe, efficient dental care when providing routine (non-emergency) dental services for members who present special challenges that require the use of general anesthesia or intravenous (IV) conscious sedation services in an:

(a) Ambulatory Surgical Center (ASC); or

(b) Inpatient or outpatient hospital setting.

(2) The Authority reimbursement for hospital dentistry is limited to covered services and may be prorated if non-covered dental services are performed during the same hospital visit.

(3) Hospital dentistry is intended for the following members:

(a) Age three (3) and younger that have extensive dental needs;

(b) Per OAR Chapter 410, Division 151, EPSDT beneficiaries are covered with the following conditions:

(A) Acute situational anxiety, fearfulness, extreme uncooperative behavior;

(B) An inability to communicate, such as a member with developmental or intellectual disability or a member who is pre-verbal;

(D) Sustained extensive orofacial or dental trauma; or

(E) Physical, mental, or medically compromising conditions.

(A) Developmental disability or other severe cognitive impairment, and one (1) or more of the following characteristics that prevent routine dental care in an office setting:

(i) Acute situational anxiety and extreme uncooperative behavior; or

(ii) A physically compromising condition.

(B) Sustained extensive orofacial or dental trauma;

(C) A medically fragile condition, such as a medical or physical condition which requires monitoring during dental procedures (i.e., coronary disease, asthma, or chronic obstructive pulmonary disease (COPD), heart failure, serious blood or bleeding disorder, or unstable diabetes or hypertension); or

(D) Have complex medical needs, contractures or other significant medical conditions potentially making the dental office setting unsafe for the member.

(4) Hospital dentistry is not intended for:

(a) Member convenience (Refer to OAR 410-120-1200);

(b) A healthy, cooperative member with minimal dental needs;

(d) Medical contraindication to general anesthesia or IV conscious sedation.

(5) The following information must be included in the member's dental record:

(a) Informed consent: Member, parental or guardian written consent must be obtained prior to the use of general anesthesia or IV conscious sedation;

(b) Justification for the use of general anesthesia or IV conscious sedation, including the following considerations:

(A) Alternative behavior management modalities;

(B) Member’s dental needs;

(D) Quantity of dental care;

(E) Member’s emotional development; and

(F) Member’s physical considerations.

(c) Documentation in the member's dental record must explain why, in the estimation of the dentist, the member may not be responsive to office treatment;

(d) The Authority or CCO may require additional documentation when reviewing requests for Prior authorization (PA) of hospital dentistry services (Refer to OAR 410-123-1160);

(e) The Authority shall require clinical documentation explaining why the dentist did not complete the previous treatment plan, if the dentist did not proceed with a previous hospital dentistry plan approved for the same member.

(6) Hospital dentistry always requires PA according to OAR 410-123-1160.

(7) For non-hospital or ASC setting anesthesia and sedation criteria refer to 410-123-1260(18).

History

Statutory/Other Authority: ORS 413.042, ORS 414.065 & 414.707
Statutes/Other Implemented: ORS 414.065 & 414.707
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 67-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 28-2013(Temp), f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13
DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13
DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12
DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 16-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08
OMAP 55-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 48-2002, f. & cert. ef. 10-1-02
OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00

Or. Admin. R. 410-123-1510 Additional Dental Benefits for Pregnant and Postpartum Members

(1) This rule sets forth the access standards for dental care for members who are pregnant or 12 months postpartum.

(2) Pregnant members must be seen, treated in person or via teledentistry for the following OHP-covered service and within the following time frames:

(a) Emergency dental care: within 24 hours;

(b) Urgent dental care: within one (1) week.

(c) Routine dental care: within four (4) weeks, unless there is a documented special clinical reason that may make it appropriate to be seen or treated beyond this time frame;

(d) Initial dental screening or examination: within four (4) weeks.

(3) The following additional dental services are available to pregnant members if authorized as medically or dentally necessary due to the pregnancy:

(a) Prophylaxis, fluoride, and periodontal services;

(b) Permanent crowns and resin-based composite crowns for anterior teeth;

(d) Root canals on first molars;

(e) Apexification/recalcification, pulpal regeneration; and

(f) Alveoloplasty not in conjunction with extractions.

(4) Nothing in this rule obligates a pregnant member to accept an offered service.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 141-2024, temporary suspend filed 12/10/2024, effective 01/01/2025 through 06/29/2025
DMAP 68-2024, minor correction filed 02/22/2024, effective 02/22/2024
DMAP 74-2022, amend filed 09/23/2022, effective 09/25/2022
DMAP 44-2022, temporary amend filed 03/29/2022, effective 04/01/2022 through 09/27/2022
DMAP 13-2022, amend filed 02/09/2022, effective 02/09/2022
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 28-2016, f. & cert. ef. 6-28-16
DMAP 82-2015(Temp), f. 12-23-15, cert. ef. 1-1-16 thru 6-28-16

Or. Admin. R. 410-123-1620 Coding and Documentation

(1) Providers must use the standardized code sets adopted by the Health Insurance Portability and Accountability Act (HIPAA) and the Centers for Medicare and Medicaid Services (CMS), and by the Chapter 410 Division 120 rules.

(2) Unless otherwise directed in this Chapter 410, Division 123 rule, providers must accurately code claims according to the national standards in effect for the date the service(s) was provided. National Code Set issuance alone may not be construed as coverage or a covered service by the Authority.

(3) The Authority or designee may review or audit providers’ claims before or after payment in accordance with OARs 410-120-1396, 410-120-1395, or 410-120-1397 and payments may be denied or subject to recovery if the review or audit determines the care, service or item;

(a) Was not provided in accordance with this Chapter 410 Division 123, or Chapter 410 Division 120 rules; or

(b) Does not meet the criteria for quality or appropriateness of payment.

(4) Procedure codes:

(a) For dental services, and procedures that are directly related to the teeth and the structures supporting the teeth, use Current Dental Terminology (CDT) codes as maintained and distributed by the American Dental Association (ADA). Contact the ADA to obtain a current copy of the CDT reference manual;

(b) For physician provided oral health services performed due to an underlying medical condition (i.e., procedures on or in preparation for treatment of the jaw, tongue, cheek, roof of mouth), use Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes; and

(5) International Classification of Diseases 10th Clinical Modification (ICD-10-CM) diagnosis codes are:

(a) Not required for dental services submitted on an ADA claim form; and

(b) Are required for medical surgical program services submitted on a professional claim form (refer to Chapter 410, Division 130).

(6) Ancillary services must be medically necessary and dentally appropriate:

(a) For medication and deep sedation provided in hospitalization, conditions must be above the funding line of the Prioritized List and are subject to the Prioritized List’s ancillary guideline notes;

(b) Some ancillary codes are not eligible for separate reimbursement (Refer to OAR 410-123-1260); and

(c) Ancillary codes covered by Medicaid are listed in Code Group 6060 and can be found by referencing data.oregon.gov/Health-Human-Services/Group-6060-Ancillary-Services/fq2m-i6ix/about_data.

(7) Records and documentation:

(a) To be eligible for reimbursement, providers must comply with all dental services rules, criteria, billing, and limits in this Chapter 410 Division 123 and Chapter 410 Division 120 and shall maintain records that fully support the extent of the service(s) and all procedure codes for which payment is requested;

(b) Providers must maintain clinical, financial and other records, capable of being audited or reviewed, as required under Chapter 410 Division 120 and Chapter 410 Division 141;

(c) Providers must keep records for seven (7) years. Providers contracted with a CCO must meet the record retention requirements in OAR 410-141-3520; and

(d) Providers must have in each client’s medical record a detailed description of the clinical indications and dental necessity of the dental service(s), including, but not limited to, the tooth number(s), surface(s), pocket depth(s), and radiographs. The provider must annotate the clinical record each time a service is provided and sign and date the record prior to submitting a claim for payment.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 93-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 139-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 70-2024, minor correction filed 02/22/2024, effective 02/22/2024
DMAP 50-2021, amend filed 12/24/2021, effective 01/01/2022
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13
DMAP 16-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 25-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 65-2003, f. 9-10-03, cert. ef. 10-1-03
OMAP 48-2002, f. & cert. ef. 10-1-02
OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 23-1999, f. & cert. ef. 4-30-99

Division 124 TRANSPLANT SERVICES

Or. Admin. R. 410-124-0000 Transplant Services

(1) The Health Systems Division (Division) shall make payment for transplant services identified in these rules as covered for eligible Medicaid clients defined in OAR 410-124-0010 that meet the transplant criteria outlined in OAR 410-124-0000 through 410-124-0040 and the Prioritized List of Health Services guideline notes.

(2) The Division shall reimburse for transplants if:

(a) All Division criteria are met; and

(b) Transplants are medically necessary and meet the requirements for physician and hospital services; and

(c) The ICD-10-CM diagnosis code(s) and CPT transplant procedure code(s) are paired on the same currently funded line on the Prioritized List of Health Services adopted under OAR 410-141-3830.

(3) The following transplants are covered by the Division if the criteria in (2) above is met:

(a) Solid organ, heart, kidney, liver, lung, heart-lung, pancreas, kidney-pancreas, and small bowel;

(b) Bone marrow and peripheral stem cell;

(d) Simultaneous multiple organ transplants are covered only if specifically identified as paired on the same currently funded line on the Oregon Health Plan (OHP) Prioritized List of Health Services whether the transplants are for the same underlying disease or for unrelated, but concomitant, underlying diseases.

(4) Not Covered Transplant Services: The following types of transplants are not covered by the Division:

(a) Transplants which are considered experimental or investigational or which are performed on an experimental or investigational basis, as determined by the Division;

(b) Second bone marrow transplants are not covered except for tandem autologous transplants for multiple myeloma.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 2-2023, temporary amend filed 01/31/2023, effective 02/01/2023 through 07/30/2023
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
OMAP 95-2004(Temp), f. & cert. ef, 12-30-04 thru 3-15-05
OMAP 92-2004(Temp), f.& cert. ef. 12-10-04 thru 3-15-05
OMAP 68-2004(Temp), f. 9-14-04, cert. ef. 10-1-04 thru 3-15-05
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 34-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 21-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 18-2000, f. 9-28-00, cert. ef. 10-1-00
HR 17-1997, f. & cert. ef. 7-11-97
HR 19-1995, f. 9-28-95, cert. ef. 10-1-95
HR 4-1994, f. & cert. ef. 2-1-94
HR 17-1992, f. & cert. ef. 7-1-92
HR 37-1990, f. 11-6-90, cert. ef. 11-9-90
HR 22-1990, f. & cert. ef. 7-17-90
HR 8-1990(Temp), f. 3-30-90, cert. ef. 4-1-90

Or. Admin. R. 410-124-0005 Donor Services

(1) Living and cadaver donor search and procurement services are covered for medically necessary transplants.

(2) All living or cadaver donor services are payable under the recipient’s Medicaid identification number and not under the donor.

(3) For Managed Care Entity(MCE) clients, contact the client’s MCE for authorization requirements.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 2-2023, temporary amend filed 01/31/2023, effective 02/01/2023 through 07/30/2023
OMAP 18-2000, f. 9-28-00, cert. ef. 10-1-00

Or. Admin. R. 410-124-0006 Transplant Hospital Requirements And Reimbursement

Transplant services shall be reimbursed only when provided in a transplant hospital that meets the Division requirements.

(1) Medicare certified transplant facility.

(2) Must be an enrolled provider with Oregon Health Authority, Health Systems Division outlined in OAR 410-120-1260.

(3) Selection of transplant hospitals by geographic location: If the services are available in the state of Oregon, reimbursement shall not be made to out-of-state transplant hospitals.

(4) Out-of-state transplant hospitals shall be considered only if:

(a) The type of transplant required is not available in Oregon and/or the type of transplant (for example, liver transplant) is available in Oregon but the Oregon transplant hospital does not provide that type of transplant for all clients or all covered diagnoses, (e.g., pediatric transplants); and

(b) An in-state transplant hospital requests the out-of-state transplant referral; and

(c) Be cost effective as determined by the Division. For example, if the transplant service is covered by the client's benefit package and the client's primary insurer (i.e., Medicare) requires the use of an out-of-state transplant hospital; or

(d) It is a contiguous, out-of-state transplant hospital that has a contract or special agreement for reimbursement with the Division.

(5) Professional and other services shall be covered according to administrative rules in the applicable provider guides.

(6) Reimbursement for covered transplants and follow-up care for transplant services is as follows:

(a) For transplants for fee-for-service clients:

(A) Transplant facility services — by contract with the Division;

(B) Professional services — at the Division's maximum allowable rates.

(b) For emergency services, when no special agreement has been established, the rate shall be:

(A) 75% of standard inpatient billed charge; and

(B) 50% of standard outpatient billed charge.

(c) For clients enrolled in Managed Care Entity (MCE), reimbursement for transplant services shall be by agreement between the MCE and the transplant hospital.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 49-2023, adopt filed 06/30/2023, effective 07/01/2023

Or. Admin. R. 410-124-0010 Eligibility for Transplant Services

(1) To be eligible for transplant services the client must be enrolled under the following Benefit Packages at the time the transplant services are provided:

(a) Oregon Health Plan Plus benefit package (BMH) described in OAR 410-120-1210 (4)(a);

(b) State funded Healthier Oregon Population (HOP) described in OAR 410-134-0003(2)(a)(C)(xiii) as of July 1, 2022.

(2) Clients covered under the following Benefit Packages do not have coverage for transplants:

(a) OHP with Limited Drugs (BMM, BMD) — coverage only for services covered by Medicare;

(b) Qualified Medicare Beneficiary (MED) — coverage only for services covered by Medicare;

(3) If an individual is not eligible for the Oregon Health Plan Plus benefit package at the time the transplant is performed, but is later made retroactively eligible for the Oregon Health Plan Plus benefit package, the Health Systems Division (Division) shall cover transplant services provided during the period of time the individual is eligible.

(4) If a client moves from fee-for-service to a Managed Care Entity (MCE), prior authorization must be obtained from the MCE if required by that MCE. If a client moves out of MCE into another MCE, or into fee-for-service, any prior authorizations approved by the original MCE are void, and prior authorization must again be obtained from the new MCE if prior authorization is required by MCE.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 2-2023, temporary amend filed 01/31/2023, effective 02/01/2023 through 07/30/2023
DMAP 22-2022, minor correction filed 02/16/2022, effective 02/16/2022
OMAP 18-2000, f. 9-28-00, cert. ef. 10-1-00
HR 19-1995, f. 9-28-95, cert. ef. 10-1-95
HR 4-1994, f. & cert. ef. 2-1-94
HR 17-1992, f. & cert. ef. 7-1-92
HR 37-1990, f. 11-6-90, cert. ef. 11-9-90

Or. Admin. R. 410-124-0040 Emergency Transplants

(1) An Emergency Transplant is one in which medical appropriateness requires that a transplant be performed less than five days after determination of the need for a transplant.

(2) Emergency transplants are subject to post transplant review of the client's medical records by the Health Systems Division (Division) or Managed Care Entity (MCE), to determine if the client and the transplant hospital met the criteria in these rules at the time of the transplant. Related charges, including transportation, physician's services, and donor charges shall be covered if payment is approved. The Division shall make payment as described in OAR 410-124 -0006 for covered transplants. MCE shall make payment as described in their contract.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 68-2023, amend filed 08/11/2023, effective 08/11/2023
DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 2-2023, temporary amend filed 01/31/2023, effective 02/01/2023 through 07/30/2023
DMAP 21-2022, minor correction filed 02/16/2022, effective 02/16/2022
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 18-2000, f. 9-28-00, cert. ef. 10-1-00
HR 4-1994, f. & cert. ef. 2-1-94
HR 22-1990, f. & cert. ef. 7-17-90
HR 8-1990(Temp), f. 3-30-90, cert. ef. 4-1-90

Division 125 HOSPITAL SERVICES

Or. Admin. R. 410-125-0000 Determining When the Patient Has Medical Assistance

(1) The Medical Card gives the client’s name as listed with the Oregon Health Plan (OHP) and their alpha-numeric prime number.

(2) Eligibility may change on a monthly basis. In some instances, eligibility will change during the month. Eligibility should be verified each time services are provided in order to assure that the client is eligible for date(s) of service. For ways to verify client eligibility see General Rule 410-120-1140.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0150
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0020 Retroactive Eligibility

(1) The Division of Medical Assistance Programs (Division) may pay for services provided to an individual who does not have Medicaid coverage at the time services are provided if the individual is made retroactively eligible for medical assistance and eligibility is extended back to the date services were provided. Contact the local branch concerning possible retroactive eligibility. In some cases, the date of branch contact may be considered the date of application for eligibility.

(2) Authorization for payment may be given after the service is provided under limited circumstances. For prior authorization information see OAR 410-125-0124 (Hospital Services Program).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0160 & 410-125-0440
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0160, 461-015-0230 & 461-015-0370
AFS 72-1989, f. & cert. ef. 12-1-90
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0030 Hospital Hold

(1) A hospital hold is a process which allows an in-state general hospital or an out-of-state contiguous general hospital to assist an individual who is admitted to the hospital for an inpatient hospital stay to secure a date of request when the individual is unable to apply for the Oregon Health Plan due to inpatient hospitalization.

(2) The Division of Medical Assistance Programs (Division) will accept hospital holds for inpatient stays. Hospitals must either submit a DMAP 3261 or a hospital generated form to Division within 24 hours of the admission time or the next working day. If a hospital uses its own form, the form must contain all the information found on the DMAP 3261.

[ED. NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 39-2000, f. 11-14-00, cert. ef. 11-15-00
OMAP 12-2000(Temp), f. 8-16-00, cert. ef. 8-17-00 thru 2-1-01

Or. Admin. R. 410-125-0040 Title XIX/Title XXI Clients

(1) Title XIX /Title XXI clients are eligible for medical assistance through programs established by the Federal government and for which the State receives federal assistance. Most Title XIX/Title XXI clients are eligible for the Plus or Standard Benefit packages. See the General rules (chapter 410 division 120) for more information on eligibility, benefit package, and covered services. Most Title XIX/Title XXI clients are enrolled in a FCHP, a MHO and a DCO. Some Title XIX clients are Medicare Beneficiaries.

(2) The Division of Medical Assistance Programs (Division) contracts with Prepaid Health Plans (PHPs): Fully-Capitated Health Plans (FCHPs), Mental Health Organizations (MHOs), and Dental Care Organizations (DCOs), to provide certain medical, mental health and dental services on a prepaid basis.

(a) FCHPs provide a comprehensive package of health care benefits including hospital, physician, laboratory, X-ray and other diagnostic imaging, Medicheck (EPSDT), pharmacy, physical therapy, speech-language therapy, occupational therapy, case management, and other services;

(b) MHOs provide mental health services. They can be fully-capitated health plans, community mental health programs, private behavioral organizations or a combination thereof;

(d) If the client is enrolled in a Prepaid Health Plan, the name, address and phone number of the plan will appear on the Medical Care Identification. Always check with the plan listed if there is a question about coverage;

(e) PHP clients receive most of their primary care services through the PHP or upon referral from the PHP. In emergency situations, all services may be provided without prior authorization or referral. However, all claims for emergency services must be sent to the prepaid health plan. The hospital must work with the client's prepaid health plan to arrange for billing and payment for emergency and non-emergency services;

(f) Division will not reimburse for services that can be provided by the client's PHP and are included in the PHP's contract as covered services. Reimbursement is between the service provider and the PHP.

(3) Medicare Clients: Some Title XIX clients also have Medicare coverage. Most Medicare beneficiaries who are also eligible for Medicaid will have the full range of covered benefits for both Medicare and Medicaid. However, a few individuals who are Medicare eligible are eligible for only partial coverage through Medicaid. Refer to the General rules (chapter, 410 division 120) for information on eligibility.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 22-1992, f. 7-31-92, cert. ef. 8-1-92
HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0060
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0170 & 461-015-0180
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0041 Non-Title XIX/XXI Clients

(1) State-funded clients are clients who have not qualified for medical assistance through a federal program but have access to medical benefits through state funded programs. There are two categories of clients who are in State-funded programs.

(2) Program General Assistance (GA) clients: Program GA clients are children in foster care, in Services to Children and Families (SCF) custody, who are not eligible for Title XIX/Title XXI programs. They have access to the full range of Medicaid covered services, but payment for services provided may be different from that for Title XIX/Title XXI clients. For additional reimbursement information see the Hospital Services Supplemental Information on the Division of Medical Assistance Programs (Division) web site.

(3) Program SF clients: Program SF clients are individuals who are receiving treatment in a state facility, such as Oregon State Hospital, or the Eastern Oregon Training Center. These clients may need to receive hospital care outside the state facility. They are entitled to the full range of Medicaid covered hospital services. These individuals will be referred by the state facility for services. They do not have Medical Care Identification cards. They are not enrolled in a Fully Capitated Health Plan. The state facility from which the client is transferred will contact the hospital regarding billing instructions for these clients.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 5-1994, f. & cert. ef. 2-1-94
HR 36-1993, f. & cert. ef. 12-1-93
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0045 Temporary rule language in effect until 12/27/2026. Coverage and Limitations

In general, most medically necessary and appropriate services are covered. There are, however, some restrictions and limitations. Please refer to the Oregon Administrative Rules (OAR) in Chapter 410, Division 120 and the Oregon Health Authority’s (Authority) other Medical Assistance OARs found in Chapter 410 for information on general scope of coverage and limitations. Some of the limitations and restrictions that apply to hospital services are:

(1) Prior authorization (PA): Some services require PA for the Oregon Health Plan (OHP) Plus Benefit Package. In order to determine which services require PA for the OHP Plus Benefit Package, refer to OAR 410-125-0080.

(2) Non-covered services:

(a) Services that are not medically necessary and appropriate, unproven medical efficacy or services that are the responsibility of another Department of Human Services (Department) or Oregon Health Authority (Authority) are not covered by the Authority’s Medical Assistance Programs;

(b) Service coverage is based on the Health Evidence Review Commission's (HERC) Prioritized List of Services and the client’s benefit package;

(c) See the general rules for the Authority’s Medical Assistance Programs (chapter 410, division 120) and other program divisions in chapter 410 for a list of services that are not covered. Further information on covered and non-covered services is found in the Revenue Code section in the Hospital Services Supplemental Information on the Oregon Health Authority’s Health Systems Division’s webpage.

(3) Limitations on hospital benefit days: Clients have no hospital benefit day limitations for treatment of covered services.

(4) Dental services: Clients have dental/denturist services identified as covered on the HERC Prioritized List (OAR 410-123-1260).

(5) Hospital services provided outside of the hospital's licensed facilities:

(a) Services provided in the client's home or in a nursing home, are not covered by the Authority as hospital services;

(b) There are a limited number of hospital services that are covered when they are provided outside a hospital’s licensed facility, which include the following:

(A) Caring Contacts services (described in OAR 333-520-0700);

(B) Maternity Case Management services (described in OAR 410-130-0595); and

(C) Specific nursing or physician services provided during a ground or air ambulance transport (described in OAR 410-136-3180).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 24-2026, temporary amend filed 06/24/2026, effective 07/01/2026 through 12/27/2026
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
HR 3-1997, f. 1-31-97, cert. ef. 2-1-97
HR 4-1995, f. & cert. ef. 3-1-95
HR 5-1994, f. & cert. ef. 2-1-94
HR 36-1993, f. & cert. ef. 12-1-93
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0050 Client Copayments

Copayments may be required for certain services and/or benefit package(s). See OAR 410-120-1230 for specific details.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 77-2002, f. 12-24-02, cert. ef. 1-1-03

Or. Admin. R. 410-125-0080 Inpatient Services

(1) Elective (not urgent or emergent) hospital admission:

(a) Coordinated Care Organization (CCO) and Mental Health Organization (MHO) clients: Contact the client’s CCO, or MHO. The health plan may have different prior authorization (PA) requirements than the Division;

(b) Medicare clients: The Division does not require PA for inpatient services provided to clients with Medicare Part A or B coverage;

(A) For a list of medical and surgical procedures that require PA, see the Division’s Medical-Surgical Services Program, rules OAR chapter 410, division 130, specifically OAR 410-130-0200, table 130-0200-1, unless they are urgent or emergent defined in OAR 410-125-0401;

(B) For PA, contact the Division unless otherwise indicated in the Medical-Surgical Service program rules, specifically OAR 410-130-0200, Table 130-0200-1.

(2) Transplant services:

(a) Complete rules for transplant services are in the Division’s Transplant Services Program rules, OAR chapter 410, division 124;

(b) Clients are eligible for transplants covered by the Oregon Health Evidence Review Commission’s Prioritized List of Health Services (Prioritized List). See the Transplant Services Program administrative rules for criteria. (3) Out-of-State non-contiguous hospitals:

(a) All non-emergent and non-urgent services provided by hospitals more than 75 miles from the Oregon border require PA;

(b) Contact the Division’s Medical Director’s office for authorization for clients not enrolled in a Prepaid Health Plan (PHP). For clients enrolled in a PHP, contact the plan.

(4) Out-of-State contiguous hospitals: The Division prior authorizes services provided by contiguous-area hospitals, less than 75 miles from the Oregon border, following the same rules and procedures governing in-state providers.

(5) Transfers to another hospital:

(a) Transfers for the purpose of providing a service listed in the Medical-Surgical Services program rules, specifically OAR 410-130-0200, Table 130-0200-1, e.g., inpatient physical rehabilitation care, require PA. (b) For transfers to a skilled nursing facility, intermediate care facility, or swing bed, contact Aging and People with Disabilities (APD). APD reimburses nursing facilities and swing beds through contracts with the facilities. For CCO clients, transfers require authorization and payment (for first 20 days) from the CCO;

(c) For transfers for the same or lesser level inpatient care to a general acute-care hospital, the Division shall cover transfers, including back transfers that are primarily for the purpose of locating the patient closer to home and family, when the transfer is expected to result in significant social or psychological benefit to the patient:

(A) The assessment of significant benefit shall be based on the amount of continued care the patient is expected to need (at least seven days) and the extent to which the transfer locates the patient closer to familial support;

(B) Payment for transfers not meeting these guidelines may be denied on the basis of post-payment review.

(d) Exceptions:

(A) Emergency transfers do not require PA;

(B) In-state or contiguous non-emergency transfers for the purpose of providing care that is unavailable in the transferring hospital do not require PA unless the planned service is listed in the Medical-Surgical Service Program rules, specifically OAR 410-130-0200, Table 130-0200-1;

(6) Dental procedures provided in a hospital setting:

(a) For prior authorization requirements, see the Division’s Dental Services Program rules; specifically OAR 410-123-1260 and 410-123-1490;

(b) Emergency dental services do not require PA;

(c) For prior authorization for fee-for-service clients, contact the Division’s Dental Services Program analyst. (See the Division’s Dental Services Program Supplemental information, http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Dental.aspx);

(d) For clients enrolled in a CCO, contact the client’s health plan.

(7) Long-term acute care (LTAC) hospital services authorization requirements:

(a) For an initial thirty-day stay:

(A) LTAC provider must, before admitting the client, submit a request for prior authorization to the Division;

(B) Include sufficient medical information to justify the requested initial stay;

(C) Meet the clinical criteria outlined in the LTAC Hospital guide at: http:www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospital.aspx.

(b) Extension of stay:

(A) Submit request for prior authorization to the Division;

(B) Include sufficient medical justification for the extended stay.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 44-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 31-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 17-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 12-2008, f. 4-29-08, cert. ef. 5-1-08
DMAP 27-2007(Temp), f. & cert. ef. 12-20-07 thru 5-15-08
OMAP 50-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 49-2004, f. 7-28-04, cert. ef. 8-1-04
OMAP 11-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 9-2002, f. & cert. ef. 4-1-02
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 4-1995, f. & cert. ef. 3-1-95
HR 5-1994, f. & cert. ef. 2-1-94
HR 36-1993, f. & cert. ef. 12-1-93
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 42-1991, f. & cert. ef. 10-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0190
HR 9-1990(Temp), f. 3-30-90, cert. ef. 4-1-90
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 38-1986, f. 4-29-86, cert. ef. 6-1-86
AFS 22-1985, f. 4-23-85, cert. ef. 6-1-85
AFS 36-1984, f. & cert. ef. 8-20-84
AFS 6-1984(Temp), f. 2-28-84, cert. ef. 3-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
AFS 11-1983, f. 3-8-83, cert. ef. 4-1-83
AFS 51-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 30-1982, f. 4-26-82, cert. ef. 5-1-82
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0085 Outpatient Services

(1) Outpatient services that may require prior authorization (PA) include (see the individual program in the Authority’s Health Systems Division (Division)) Oregon Administrative Rules:

(a) Physical Therapy (chapter 410, division 131);

(b) Occupational Therapy (chapter 410, division 131);

(d) Audiology (chapter 410, division 129);

(e) Hearing Aids (chapter 410, division 129);

(f) Dental Procedures (chapter 410, division 123);

(g) Drugs (chapter 410, division 121);

(h) Apnea monitors, services, and supplies (chapter 410, division 122);

(i) Home Parenteral/Enteral Therapy (chapter 410, division 148);

(j) Durable Medical Equipment and Medical supplies (chapter 410, division 122);

(k) Certain hospital services.

(2) The National Drug Code (NDC) must be included on the electronic (837I) and paper (UB 04) claims for physician administered drug codes required by the Deficit Reduction Act of 2005.

(3) Outpatient surgical procedures:

(a) For Coordinated Care Organization (CCO) members: Contact the CCO. The CCO may have different PA requirements than the Division. Some services are not covered under CCO contracts and require PA from the Division, or the Division’s Dental Services program analyst;

(b) For Medicare clients enrolled in a CCO: These services must be authorized by the CCO even if Medicare is the primary payer. Without this authorization, the provider may not be paid beyond any Medicare payments (see also OAR 410-125-0103);

(A) Surgical procedures listed in OAR 410-125-0080 require PA when performed in an outpatient or day surgery setting, unless they are urgent or emergent;

(B) Contact the Division for PA (unless indicated otherwise in OAR 410-125-0080).

(d) Out-of-State services: Outpatient services provided by hospitals located less than 75 miles from the border of Oregon do not require PA unless specified in the Division’s Hospital Services Program rules. All non-urgent or non-emergent services provided by hospitals located more than 75 miles from the border of Oregon require PA. For clients enrolled in a CCO, contact the CCO for authorization. For clients not enrolled in a health plan, contact the Division’s Provider Clinical Support Unit.

(4) Psychiatric Emergency Services (PES):

(a) Psychiatric emergency services as defined by OAR 309-023-0110 delivered in a PES facility as described in OAR 309-023-0120 shall be reimbursed for a maximum of 20 hours per admittance;

(b) Psychiatric emergency services shall be reimbursed with a bundled, hourly rate using a fee-for-service rate methodology that is based on rates paid for similar services, using similar providers at a similar level-of-care.

(5) High-Cost Drug Carve-Out (HCDCO) products:

(a) Drugs and biologics included in the HCDCO referenced in OAR 410-141-3855 will be carved out from the inpatient Diagnosis Related Grouper (DRG) and will be reimbursed on an outpatient claim when drugs are administered during an inpatient stay.

(b) The Agency will reimburse for HCDCO drugs and biologics billed on an outpatient claim at the actual acquisition cost according to invoice, up to Wholesale Acquisition Cost (WAC).

(6) Long-Acting Reversible Contraceptives (LARCs):

(a) LARCs will be carved out from the inpatient Diagnosis Related Grouper (DRG) and will be reimbursed on an outpatient claim when they are administered during an inpatient stay.

(b) The Agency will reimburse the LARCs billed on an outpatient claim at the Wholesale Acquisition Cost (WAC).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 92-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 77-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 63-2016(Temp), f. & cert. ef. 11-10-16 thru 5-8-17
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 4-1995, f. & cert. ef. 3-1-95
HR 5-1994, f. & cert. ef. 2-1-94
HR 36-1993, f. & cert. ef. 12-1-93
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0086 Prior Authorization for FCHP/MHO Clients

Most non-emergent inpatient and outpatient services require prior authorization by a Fully Capitated Health Plan (FCHP) or a Mental Health Organization (MHO). Emergency hospital services must be covered by an FCHP or MHO without regard to prior authorization or the emergency care provider’s contractual relationship with the FCHP or MHO. Emergency hospital services are defined as covered inpatient and outpatient services that are needed to evaluate or stabilize an emergency medical condition. Once a client’s condition is considered stabilized, or a medical screening examination has determined that the client’s medical condition is not emergent, an FCHP or MHO may require prior authorization for hospital admission, follow-up care, or further treatment. Failure to obtain prior authorization from the FCHP or MHO may result in a denial of payment for services. Contact the client’s FCHP or MHO for further information on prior authorization.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 36-1993, f. & cert. ef. 12-1-93
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0090 Inpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals

(1) The Office of Rural Health designates Type A, Type B, and Critical Access Oregon Hospitals.

(2) Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered inpatient services is as follows:

(a) Interim reimbursement for inpatient covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except laboratory and radiology services are based on the Division of Medical Assistance Program’s (Division) fee schedule;

(b) Retrospective cost-based reimbursement is made during the annual cost settlement period for all covered inpatient services, except for the hospitals that have payment contracts with managed care plans;

(c) Cost-based reimbursement; is derived from the most recent audited Medicare Cost Report and adjusted to reflect the Medicaid mix of services.

(3) Type A, Type B, and Critical Access Hospitals are:

(a) Eligible for disproportionate share reimbursements, but must meet the same criteria as other hospitals. See OAR 410-125-0150 for eligibility criteria and reimbursement calculation;

(b) Type A, Type B, and Critical Access Hospitals do not receive cost outlier, capital, or medical education payments.

(4) Notwithstanding subsection (2) of this rule, this subsection becomes effective for dates of service on and after January 1, 2006, but will not be operative as the basis for payments until Division determines all necessary federal approvals have been obtained. Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered inpatient services is as follows:

(a) Interim reimbursement for inpatient-covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except clinical laboratory services which are based on the Division fee schedule;

(b) Retrospective cost-based reimbursement is made for all fee-for-service covered inpatient services during the annual cost settlement period;

(c) Cost-based reimbursement is derived from the most recent audited Medicare Cost Report and adjusted to reflect the Medicaid mix of services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
HR 36-1993, f. & cert. ef. 12-1-93
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 68-1981, f. 9-30-81, cert. ef. 10-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0095 Hospitals Providing Specialized Inpatient Services

(1) Some hospitals provide specific highly specialized in patient services by arrangement with the Division.

(2) Reimbursement is made according to the terms of a contract between the Division and the hospital.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 68-1981, f. 9-30-81, cert. ef. 10-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0101 Hospital-Based Nursing Facilities and Medicaid Swing Beds

To be eligible to receive reimbursement for hospital-based long-term care nursing facility services or Medicaid swing beds, the hospital must:

(1) Have approval from the Centers for Medicare and Medicaid Services (CMS) to furnish skilled nursing facility services as a Medicare hospital swing bed unit,

(2) Be enrolled and have a current signed HSD provider agreement,

(3) Services must be provided, billed, separate from other hospital services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 94-2023, amend filed 12/22/2023, effective 01/01/2024
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 68-1981, f. 9-30-81, cert. ef. 10-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0102 Medically Needy Clients

(1) The QIO can give prior authorization for non-emergency inpatient services for clients who are in the Medically Needy Program but have not yet met their spend-down. Only Medically Needy Program clients under age 21 and pregnant women have coverage for inpatient services if enrolled in the Medically Needy Program.

(2) Prior authorization cannot be granted for outpatient services, which require prior authorization. However, you may contact the Division Medical/ Dental Group once the client has been made eligible and request retroactive authorization.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0103 Medicare Clients

When Medicare is the primary payer, services provided in the inpatient or out-patient setting do not require prior authorization. However, if the Division is the primary payer because the service is not covered by Medicare; the prior authorization requirements listed in chapter 410 division 125 would apply.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0115 Non-Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003

Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Unless such hospitals have an agreement or contract with Division of Medical Assistance Programs (Division) for specialized services, non-contiguous area out-of-state hospitals will receive DRG reimbursement or billed charges whichever is less. The unit value for non-contiguous out-of-state hospitals will be set at the final unit value for the 50th percentile of Oregon hospitals (see Inpatient Rate Calculations from Other Hospitals, DRG Rate Methodology, OAR 410-125-0141 for the methodology used to calculate the unit value at the 50th percentile). No cost outlier, capital or medical education payments will be made. The hospital will receive a disproportionate share reimbursement if eligible (see OAR 410-125-0150).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 27-2004, f. 4-22-04 cert. ef. 5-1-04
OMAP 16-2004(Temp), f. & cert. ef. 3-15-04 thru 8-15-04
OMAP 58-2003, f. 9-5-03, cert. ef. 10-1-03
HR 53-1991, f. & cert. 11-18-91, Renumbered from 410-125-0840
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 3-1991, f. & cert. ef. 1-4-91
HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570
HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0120 Transportation To and From Medical Services

(1) Transportation to and from medical services, including hospital services, is a covered service. However, all non-emergency transports require prior authorization in order for the transportation provider to be paid.

(2) Interfacility transfers are defined as bed optimization and balancing resource management strategies for the purpose of patient movement across a health network system. The transfer of patients between hospitals, form hospitals to specialized care facilities, or bed to bed lateral transfers within the same health provider network system.

(a) Interfacility transfers are not a covered service by the Agency unless they meet medically necessary criteria.

(b) Interfacility transfers are considered medically necessary when one or more of the following criteria are met:

(A) The patient requires medically necessary diagnostic or therapeutic services that are not available at the originating facility; or

(B) The patient requires a higher-level of care which is not available at the originating facility; or

(C) The patient has received care at a prior facility for a condition that is not normally managed at the originating facility and the return to the prior facility is needed to diagnose, manage, or treat a complication or other acute issue.

(3) The transportation must be the least expensive obtainable under existing conditions and appropriate to the client's needs.

(4) Contact the Division-contracted regional Transportation Brokerage (Brokerage) for prior authorization for the transport or instruct the transportation provider to contact the Brokerage. Brokerage map and contact information is available at https://www.oregon.gov/oha/HSD/OHP/Tools/Transportation%20Brokerage%20Map.pdf

(5) Hospitals must follow the after hours procedures for the Brokerages and contact the appropriate after hours providers for non-emergent transportation for hospital discharges.

(6) No prior authorization is required when the client's condition requires emergency transport.

(7) When a hospital sends a patient to another facility or provider during the course of an inpatient stay and the client is returned to the admitting hospital within 24 hours, the hospital must arrange for and pay for the transportation. See billing instructions contained in the Hospital Supplemental Information on the Division website for additional information.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 55-2025, amend filed 06/26/2025, effective 06/29/2025
DMAP 45-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0210
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0121 Contiguous Area Out-of-State Hospitals

Contiguous area hospitals are out-of-state hospitals located less than 75 miles outside the Oregon border. Unless such hospitals have an agreement or contract with the Agency for specialized services, contiguous area out-of-state hospitals shall receive DRG reimbursement or billed charges whichever is less. The unit value for contiguous out-of-state hospitals shall be set at the final unit value for the 50th percentile of Oregon hospitals (see Inpatient Rate Calculations for Other Hospitals, DRG Rate Methodology OAR 410-125-0141 for the methodology). Contiguous area out-of-state hospitals are also eligible for cost outlier payments. No capital or medical education payments shall be made. The hospital shall receive a disproportionate share reimbursement if eligible (see OAR 410-125-0150).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 55-2025, amend filed 06/26/2025, effective 06/29/2025
DMAP 146-2024, temporary amend filed 12/29/2024, effective 01/01/2025 through 06/29/2025
OMAP 27-2004, f. 4-22-04 cert. ef. 5-1-04
OMAP 16-2004(Temp), f. & cert. ef. 3-15-04 thru 8-15-04
OMAP 58-2003, f. 9-5-03, cert. ef. 10-1-03
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0840
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 3-1991, f. & cert. ef. 1-4-91
HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570
HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
AFS 60-1982, f. & cert. ef. 7-1-82; Renumbered from 461-015-0120(5)
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0124 Retroactive Authorization

Retroactive authorization for payment can be granted after the service is provided only in the following circumstances:

(1) The person was not yet eligible for Medicaid/CHIP at the time the services were provided. Payment can be made if the services are covered Medicaid/CHIP services and the client's eligibility is extended back to the date the hospital provided services. See: the Hospital Services Supplemental Information on the Division of Medical Assistance Programs (Division) website for additional billing information.

(2) If another insurer denied the claim because the service is not covered by that insurer, and the hospital did not seek prior authorization because it had good reason to believe the service was covered by the insurer. Payment can be made by the Division if the services are covered by Medicaid. See: the Hospital Services Supplemental Information on the Division website for additional billing information.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0125 Free-Standing Inpatient Psychiatric Facilities

Free-standing inpatient psychiatric facilities (institutions for mental diseases), including Oregon's state-operated psychiatric and training facilities, are reimbursed according to the terms of an agreement between the Addictions and Mental Health, Aging and People with Disabilities, and the hospital.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991 (Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989 (Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987 (Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 68-1981, f. 9-30-81, cert. ef. 10-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0140 Prior Authorization Does Not Guarantee Payment

(1) Prior authorization (PA) is valid for the date range approved only as long as the client remains eligible for services. For example, a client may become ineligible after the PA has been granted but before the actual date of service, or a client's hospital benefit days may be used prior to the time the claim for the prior authorized service is submitted to the Division of Medical Assistance Programs (Division) for payment.

(2) All prior authorized treatment are subject to retrospective review. If the information provided to obtain PA cannot be validated in a retrospective review, payment shall be denied or recovered.

(3) Hospitals should develop their own internal monitoring system to determine if the admitting physician has received PA for the service from the Division.

(4) For the Plus Benefit Package PA information refer to the PA chart in the Hospital Services Program OAR 410-125-0080.

(5) Hospitals may also verify PA requirements by calling the Division’s Provider Services Unit or the RN Benefit Hotline (contact phone numbers are located on the Division’s website).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0220
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0141 DRG Rate Methodology

(1) Diagnosis Related Groups, (DRG):

(a) The DRG is a system of classification of diagnoses and procedures based on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM);

(b) The DRG classification methodology assigns a DRG category to each inpatient service, based on the patient’s diagnoses, age, procedures performed, length of stay, and discharge status.

(2) Medicare Grouper: The Medicare Grouper is the software used to assign an individual claim to a DRG category. Medicare revises the Grouper program each year in October. The Agency uses the Medicare Grouper program in the assignment of inpatient hospital claims. The most recent version of the Medicare grouper shall be installed each year within ninety (90) days of the date it is implemented by Medicare. Where better assignment of claims is achieved through changes to the grouper logic, the Agency may modify the logic of the grouper program. The Agency shall work with representatives of hospitals that may be affected by grouper logic changes in reaching a cooperative decision regarding changes. The Agency DRG weight tables can be found on the Agency web site:

(a) Acute Care Hospitals larger than fifty (50) beds are considered DRG hospitals and reimbursed using Medicare’s MS-DRG grouper;

(b) Hospitals enrolled as long-term acute care (LTAC) are reimbursed using Medicare’s MS-LTC DRG grouper.

(c) Inpatient psychiatric adult and pediatric services are reimbursed using the most recent Medical Severity Diagnosis Related Groups, (MS-DRG), in Major Diagnosis Category, (MDC), MDC-19 and MDC-20 published by Medicare in the latest inpatient Prospective Payment System, (IPPS) final rule.

(3) DRG Relative Weights:

(a) Relative weights are a measure of the relative resources required in the treatment of the average case falling within a specific DRG category;

(b) For most DRGs, the Agency establishes a relative weight based on federal Medicare DRG weights. For state-specific Rehabilitation, and Neonate, Oregon Title XIX fee-for-service claims history is used. The Agency employs the following methodology to determine whether enough claims exist to establish a reasonable weight for each state-specific Rehabilitation, and Neonate, the Agency uses the following methodology: Using the formula N = ((Z * S)/ R)^2, where Z=1.15(a 75 percent confidence level), S is the standard deviation, and R = 10 percent of the mean. The Agency determines the minimum number of claims required to set a stable weight for each DRG (N must be at least 5). For state-specific Rehabilitation, and Neonate, lacking sufficient volume, the Agency sets a relative weight using:

(A) Agency non-Title XIX claims data; or

(B) Data from other sources expected to reflect a population similar to the Agency Title XIX caseload;

(c) When a test shows at the 90 percent confidence level that an externally derived weight is not representative of the average cost of services provided to the Agency Title XIX population in that DRG, the weight derived from the Agency Title XIX claims history is used instead of the externally derived weight for that DRG;

(d) Those relative weights based on Federal Medicare DRG weights shall be established when changes are made to the DRG Grouper logic. State-specific relative weights shall be adjusted, as needed, as determined by the Agency. When relative weights are recalculated, the overall Case Mix Index (CMI) shall be kept constant. Reweighing of DRGs or the addition or modification of the grouper logic shall not result in a reduction of overall payments or total relative weights.

(4) Case Mix Index: The hospital-specific case mix index is the total of all relative weights for all services provided by a hospital during a period, divided by the number of discharges.

(5) Unit Value: Hospitals larger than fifty beds or enrolled as a long-term acute care (LTAC) hospital are reimbursed using the DRG as described in section (2). Effective for services on or after:

(a) Effective October 1, 2009 the operating unit payment is 100 percent of the most recent version of the Medicare base payment rates. The Agency shall revise the base payment rates each year in October when Medicare posts the rates.

(b) DRG Payment: The DRG payment to each Oregon DRG hospital or LTAC hospital is calculated by adding the unit value to the capital amount, then multiplied by the claim assigned DRG relative weight (out-of-state hospitals do not receive the capital amount).

(c) Effective January 1, 2025; the Agency shall establish separate unit values for inpatient psychiatric adult and pediatric services. The unit values shall apply to the DRGs published in the most recent Major Diagnostic Category (MDC) group 19 and 20 and be multiplied by the claim-assigned DRG relative weight. The adult and pediatric psychiatric unit values for each hospital have been established as a percentage of the estimated Medicaid costs for inpatient hospital psychiatric services based on calendar year 2021 and 2022 Oregon inpatient hospital claims and the applicable Medicare cost reports.

(6) The unit values for inpatient psychiatric adult and pediatric services are adjusted for the location of the hospital. The calculated labor portion of unit values are multiplied by the wage index as identified in the Medicare Inpatient Prospective Payment System Final Rule (IPPS Final Rule) to determine the location adjusted labor portion and the capital portion of the unit values are multiplied by the geographic adjustment factor as outlined in the IPPS Final Rule. The total unit value for each hospital equals the sum of the wage-adjusted labor portion, the non-labor portion and geographic-adjusted capital portion shall be rebased every two (2) years or at the discretion of the Agency. During non-rebase years, the adult and pediatric psychiatric unit values shall be updated using the Medicare increases in the Medicare market basket increases from the IPPS Final Rule effective October 1st of the non-rebase year.

(7) DRG Hospital Cost Outlier Payments:

(a) Cost outlier payments are an additional payment made to in-state and contiguous hospitals for exceptionally costly services or exceptionally long lengths of stay provided to Title XIX and SF (State Facility) clients. As of January 1, 2025, outlier payments for inpatient hospital psychiatric services follow the methodology outlines in Section (10);

(b) The calculation to determine the cost outlier payment for Oregon DRG hospitals is as follows:

(A) Non-covered services (such as ambulance charges) are deducted from billed charges;

(B) The remaining billed charges are converted to hospital-specific costs using the hospital’s cost-to-charge ratio derived from the most recent audited Medicare cost report and adjusted to the Medicaid caseload;

(C) If the hospital’s net costs as determined above are greater than 270 percent of the DRG payment for the admission and are greater than $25,000, an additional cost outlier payment is made;

(D) Costs which exceed the threshold ($25,000 or 270 percent of the DRG payment, whichever is greater) are reimbursed using the following formula:

(i) Billed charges less non-covered charges, multiplied by;

(ii) Hospital-specific cost-to-charge ratio equals;

(iii) Net Costs, minus;

(iv) 270 percent of the DRG or $25,000 (whichever is greater), equals;

(v) Outlier Costs, multiplied by;

(vi) Cost Outlier Percentage, (cost outlier percentage is 50 percent), equals;

(vii) Cost Outlier Payment;

(E) Third party reimbursements are deducted from the Agency calculation of the payable amount;

(F) When hospital cost reports are audited during the cost settlement process, an adjustment shall be made to cost outlier payments to reflect the actual Medicaid hospital-specific cost-to-charge ratio during the time cost outlier claims were incurred. The cost-to-charge ratio in effect for that period of time shall be determined from the audited Medicare Cost Report and cost statement template, adjusted to reflect the Medicaid mix of services.

(8) LTAC Short Stay Outliers: Occurs when a covered length of stay is between one day and up to and including 5/6ths of the average length of stay for the LTC-DRG grouping. The Short Stay Outlier payment for the hospital shall be the lesser of:

(a) Per Diem for Short Stay Outlier Calculation:

(A) MS-LTC DRG payment, divided by;

(B) Geometric Length of Stay (GLOS,) multiplied by;

(D) 120 percent equals;

(E) Per Diem payment;

(b) Full MS-LTC DRG payment.

(9) LTAC High Cost Outliers: Are an additional payment when the estimated cost of a claim exceeds the outlier threshold (LTC DRG payment plus a fixed loss amount):

(a) The fixed loss amount is published annually by Medicare;

(b) If the estimated cost of a claim is greater than the outlier threshold, an additional payment is added to the LTC DRG payment;

(c) The outlier payment is 80 percent of the difference between the estimated cost of the claim and the outlier threshold (LTC DRG payment plus the fixed loss amount);

(d) The estimated cost of the claim is calculated by multiplying the Agency’s allowable charge on the claim by the hospital’s cost-to-charge ratio.

(10) Inpatient psychiatric adult and pediatric services day outlier payment:

(a) Effective for services on or after January 1, 2025; a day outlier shall be applied to inpatient psychiatric adult and pediatric services when the outlier threshold is met. The outlier threshold is a sliding scale starting at a length of stay thirty (30) days. The sliding scale determines the adjustment percentage for the calculation.

(b) Adjustment percentage sliding scale effective on or after January 1, 2025:

(A) Percentage scale for days of service 30-89 is 70 percent

(B) Percentage scale for days of service 90 plus is 50 percent

(11) Day outlier formula calculation effective on or after January 1, 2025:

(a) Unit value as defined in (5)(c);

(b) Multiplied by the DRG weight equals DRG base payment;

(d) DRG per diem multiplied by days over the 30-day threshold, equals DRG outlier;

(e) DRG day outlier times the DRG Day Outlier Percentage equals allowable DRG outlier.

(f) Formula, unit value (70 percent of Medicare) X DRG weight=DRG base payment/ DRG ALOS= DRG per diem X days over 30-day threshold= DRG outlier X DRG day outlier percentage= allowable DRG outlier.

(12) Capital:

(a) The capital payment is a reimbursement to in-state hospitals for capital costs associated with the delivery of services to Title XIX, non-Medicare persons. The Agency uses the Medicare definition and calculation of capital costs. These costs are taken from the Hospital Statement of Reimbursable Cost (Medicare Report); capital cost per discharge is calculated as follows:

(b) The capital cost per discharge is 100 percent of the current year Medicare capital rate for non-psychiatric services and updated every October thereafter, see section (5) of this rule. The capital cost is added to the Unit Value and paid per discharge for non-psychiatric services.

(c) There is no separate cost reimbursement for capital cost for adult and pediatric inpatient psychiatric services as it is captured in the unit value per section (5)(c).

(13) Direct Medical Education:

(a) The direct medical education payment is a reimbursement to in-state hospitals for direct medical education costs associated with the delivery of services to Title XIX eligible persons. The Agency uses the Medicare definition and calculation of direct medical education costs. These costs are taken from the Hospital Statement of Reimbursable Cost (Medicare Report);

(b) Direct medical education cost per discharge is calculated as follows:

(A) The direct medical education cost proportional to the number of Title XIX non-Medicare discharges during the period from July 1, 1986, through June 30, 1987, are divided by the number of Title XIX non-Medicare discharges. This is the Title XIX direct medical education cost per discharge;

(B) The Title XIX direct medical education cost per discharge for this period is inflated forward to January 1, 1992, using the compounded HCFA-DRI market basket adjustment;

(A) The number of Title XIX non-Medicare discharges from each hospital for the quarterly period is multiplied by the inflated Title XIX cost per discharge. This determines the current quarter’s Direct Medical Education costs. This amount is then multiplied by 85 percent. Payment is made within thirty days of the end of the quarter;

(B) The Direct Medical Education Payment per Discharge shall be adjusted at an inflation factor determined by the Department in consideration of inflationary trends, hospital productivity, and other relevant factors.

(i) On July 1, 2006, and thereafter direct medical education payments shall not be made to hospitals; and

(ii) On July 1, 2008,and thereafter direct medical education payments shall be made to hospitals.

(14) Indirect Medical Education:

(a) The indirect medical education payment is a reimbursement made to in-state hospitals for indirect medical education costs associated with the delivery of services to Title XIX non-Medicare clients;

(b) Indirect medical education costs are those indirect costs identified by Medicare as resulting from the effect of teaching activity on operating costs;

(c) Indirect medical education payments are made to in-state hospitals determined by Medicare to be eligible for such payments. The indirect medical education factor in use by Medicare for each of these eligible hospitals at the beginning of the state’s fiscal year is the Agency indirect medical education factor. This factor is used for the entire Oregon Fiscal Year;

(d) For dates of service on and after March 1, 2004, the calculation for the Indirect Medical Education quarterly payment is as follows: Total paid discharges during the quarter multiplied by the Case Mix Index, multiplied by the hospital-specific February 29, 2004, Unit Value, multiplied by the Indirect Factor, equals the Indirect Medical Education Payment;

(e) Effective October 1, 2009, the calculation of the Indirect Medical Education quarterly payment is as follows: Total paid discharges during the quarter multiplied by the Case Mix Index, multiplied by the hospital unit value, see section (5)(c) of this rule, multiplied by the indirect factor, equals the Indirect Medical Education Payment;

(f) This determines the current quarter’s Indirect Medical Education Payment. Indirect medical education payments are made quarterly to each eligible hospital. Payment for indirect medical education costs shall be made within thirty (30) days of the end of the quarter;

(g) Notwithstanding section (10) of this rule, this subsection becomes effective for dates of service:

(A) On July 1, 2006, and thereafter Indirect Medical Education payment shall not be made to hospitals; and

(B) On July 1, 2008, and thereafter Indirect Medical Education payments shall be made to hospitals.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 90-2025, amend filed 12/17/2025, effective 12/17/2025
DMAP 59-2025, temporary amend filed 07/30/2025, effective 08/01/2025 through 01/27/2026
DMAP 55-2025, amend filed 06/26/2025, effective 06/29/2025
DMAP 146-2024, temporary amend filed 12/29/2024, effective 01/01/2025 through 06/29/2025
DMAP 31-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 31-2009, f. 9-22-09, cert. ef. 10-1-09
DMAP 10-2009(Temp), f. 4-29-09, cert. ef. 5-1-09 thru 10-28-09
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 70-2005, f. 12-21-05, cert. ef. 1-1-06
OMAP 37-2005(Temp), f. & cert. ef. 8-15-05 thru 1-15-06
OMAP 21-2005, f. 3-21-05, cert. ef. 4-1-05
OMAP 78-2004(Temp), f. & cert. ef. 10-1-04 thru 3-15-05
OMAP 90-2003, f. 12-30-03, cert. ef. 1-1-04
OMAP 37-2003, f. & cert. ef. 5-1-03
OMAP 16-2003(Temp), f. & cert. ef. 3-10-03 thru 8-1-03
OMAP 13-2003, f. 2-28-03, cert. ef. 3-1-03
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 34-1999, f. & cert. ef. 10-1-99
OMAP 45-1998, f. & cert. ef. 12-1-98
HR 22-1996, f. 11-29-96, cert. ef. 12-1-96
HR 11-1996(Temp), f. & cert. ef. 7-1-96
HR 23-1994, f. 5-31-94, cert. ef. 6-1-94
HR 35-1993(Temp), f. & cert. ef. 12-1-93
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0840, 410-125-0880, 410-125-0900, 410-125-0920, 410-125-0960 & 410-125-0980
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 3-1991, f. & cert. ef. 1-4-91
HR 42-1990, f. & cert. ef. 11-30-90
HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570, 461-015-0590, 461-015-0600 & 461-015-0610
HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
AFS 60-1982, f. & cert. ef. 7-1-82; Renumbered from 461-015-0120(5)
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0142 Graduate Medical Education Reimbursement for Public Teaching Hospitals

(1) Graduate medical education payment is reimbursement made to an institution for the costs of an approved medical training program. The State makes GME payments to any in-state public acute care hospital providing a major teaching program, defined as a hospital with more than 200 residents or interns. Funding for public teaching hospital GME is not included in the "capitation rates" paid to managed care plans under the Oregon Health Plan resulting in hospitals with medical teaching programs not being able to capture GME costs when contracting with managed care plans.

(2) For each qualifying public hospital, the payment amount is initially determined based on hospital specific costs for medical education as reported in the Medicare Cost Report for the most recent completed reporting year (becomes base year).

(3) The GME payment is calculated as follows:

(a) Total direct medical education (DME) costs consist of the costs for medical residency and the paramedical education programs. Title XIX DME costs are determined based on the ratio of Title XIX days to total days applied to the total DME.

(b) Indirect medical education (IME) costs are derived by first computing the percent of IME to total Medicare inpatient payments. This is performed by dividing the IME Adjustment reported in the Medicare Cost Report by the sum of this amount and Medicare payments for DRG amount — other than outlier payments, inpatient program capital, and organ acquisition. The resulting percent is then applied to net allowable costs (total allowable costs less Total DME costs, computed as discussed in the previous paragraph). Title XIX IME costs are then determined based upon the ratio of Title XIX days to total days.

(c) The total net Title XIX GME is the sum of Title XIX IME and DME costs. The GME reimbursement is made quarterly. Reimbursement is limited to the availability of public funds, specifically, the amount of public funds available for GME attributable to the Title XIX patient population. GME is rebased yearly.

(4) Total GME payments will not exceed that determined by using Medicare reimbursement. The Medicare upper limit will be determined from the most recent Medicare Cost Report and performed for all inpatient acute hospitals and separately for State operated inpatient acute hospitals in accordance with 42 CFR 447.272(a) and (b). The upper limit review will be performed before the GME payment is made.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 34-1999, f. & cert. ef. 10-1-99
OMAP 30-1999(Temp), f. & cert. ef. 6-15-99 thru 11-1-99

Or. Admin. R. 410-125-0146 Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners

(1) Effective for dates of service on or after November 17, 2005, physician and other practitioner services provided by practitioners affiliated with a public academic medical center that meets the following eligibility standards shall be eligible for a supplemental teaching practitioner's payment for these services provided to eligible Medicaid recipients and paid for directly on a fee-for-service basis, subject to subsections (3) and (4) of this rule. This supplemental payment shall be equal to the difference between the Medicare allowable and Medicaid reimbursement received.

(2) Eligible academic medical centers must be:

(a) The hospital must be located within the State of Oregon (border hospitals are excluded); and

(b) The hospital provides a major medical teaching program, defined as a hospital with more than 200 residents or interns.

(3) Payments under this rule shall be made only to the eligible academic medical centers in accordance with the terms of an intergovermental agreement between the eligible academic medical center and Division of Medical Assistance Programs (Division). Such payments may be made quarterly, but shall be at least paid annually, at the end of each federal fiscal year. Calculation of the payment amount will be based on the annual difference between the practitioners' Medicare allowable and the Medicaid allowable payments to eligible practitioners for the Medicaid claims paid during the most recently completed state fiscal year. Services included are physician and other practitioners' services with RVU weights and physician-administered drugs. The RVU rates used for the payment calculation are the Division’s fee established in rule for the date of service payment period.

(4) Allowable Medicaid payments including this supplemental payment remain subject to OAR 410-125-0220(12) and 410-130-0225. For purposes of this rule, the allowable Medicaid payments used to calculate the supplemental payment shall be limited to the services that are billed fee-for-service to the Division on the electronic 837P or the paper CMS-1500, and as to which the physician or practitioner is receiving no reimbursement from the eligible academic medical center and the cost of their service is not reported as a direct medical education cost on the Medicare and the Division’s cost report.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.065
OMAP 43-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 33-2006, f. 8-31-06, cert. ef. 9-1-06

Or. Admin. R. 410-125-0150 Disproportionate Share

(1) The Disproportionate-share hospital (DSH) payment is an additional reimbursement made to hospitals that serve a disproportionate share of low-income patients with special needs.

(a) To receive DSH payments, a hospital must have at least two obstetricians with staff privileges at the hospital who have agreed to provide non-emergency obstetrical services to Medicaid patients. For hospitals in a rural area (outside of a Metropolitan Statistical Area, as defined by the Executive Office of Management and Budget), the term "obstetrician" includes any physician with staff privileges at the hospital that performs non-emergency obstetric procedures. This requirement does not apply to a hospital in which a majority of inpatients are under 18 years of age, or a hospital that had discontinued or did not offer non-emergency obstetric services as of December 21, 1987. No hospital may qualify for disproportionate share payments unless the hospital has, at a minimum, a Medicaid utilization rate of 1 percent. The Medicaid utilization rate is the ratio of total paid Medicaid (Title XIX, non-Medicare) days to total inpatient days. Newborn days, days in specialized wards, and administratively necessary days are included. Days attributable to individuals eligible for Medicaid in another State are also accounted for;

(b) Information on total inpatient days is taken from the most recent Medicare Cost Report.

(2) A hospital's eligibility for DSH payments is determined at the beginning of each fiscal year. Hospitals that are not eligible under Criteria 1 may apply for eligibility at any time during the year under Criteria 2. A hospital may be determined eligible under Criteria 2 only after being determined ineligible under Criteria 1.

(3) Eligibility under Criteria 2 is effective from the beginning of the quarter in which eligibility is approved. Out-of-state hospitals are eligible for DSH payments if they have been designated by their state Title XIX Medicaid program as eligible for DSH payments within that state:

(a) Criteria 1: One or more standard deviation above the mean

(A) The ratio of total paid Medicaid inpatient (Title XIX, non-Medicare) days for hospital services (regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity) to total inpatient days is one or more standard deviations above the mean for all Oregon hospital;

(B) Information on total inpatient days is taken from the most recent audited Medicare Cost Report. The total paid Medicaid inpatient days is based on Division of Medical Assistance Programs’ (Division) records for the same cost reporting period;

(C) Information on total paid Medicaid days is taken from Division reports of paid claims for the same fiscal period as the Medicare Cost Report.

(b) Criteria 2: A low-income utilization rate exceeding 25 percent

(A) The Low income utilization rate is the sum of percentages (3)(b)(A)(i) and (3)(b)(A)(ii) below:

(i) The Medicaid percentage: The total of Medicaid inpatient and outpatient revenues paid to the hospital for hospital services (regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity) plus any cash subsidies received directly from State and local governments in the most recent Medicare cost reporting period. This amount is divided by the total amount of inpatient and outpatient revenues and cash subsidies of the hospital for patient services in the most recent Medicare cost reporting period. The result is expressed as a percentage;

(ii) The charity care percentage: The total hospital charges for inpatient hospital services for charity care in the most recent Medicare cost reporting period, minus any cash subsidies received directly from State and local government in the same period is divided by the total amount of the hospital's charges for inpatient services in the same period. The result is expressed as a percentage;

(iii) Charity care is provided to individuals who have no source of payment, including third party and personal resources.

(B) Charity care shall not include deductions from revenues or the amount by which inpatient charges are reduced due to contractual allowances and discounts to other third party payers, such as Fully-Capitated Health Plans (FCHPs), Medicare, Medicaid, etc;

(i) The most recent Medicare Cost Reports;

(ii) The Division’s records of payments made during the same reporting period;

(iii) Hospital-provided financial statements, prepared and certified for accuracy by a licensed public accounting firm for the same reporting period;

(iv) Hospital-provided official records from state and county agencies of any cash subsidies paid to the hospital during the same reporting period;

(v) Any other information that the Division, working in conjunction with representatives of Oregon hospitals, determines is necessary to establish eligibility.

(D) The Division determines within 30 days of receipt of all required information if a hospital is eligible under the low income utilization rate criteria.

(A) All hospitals that have been deemed DSH hospitals will always qualify for DSH payments under criteria 1 or criteria 2. Hospital ranking is done on an annual basis for all hospitals. Once eligible hospitals are determined Division calculates the standard deviations for the hospitals to determine if they will be eligible under criteria 1 or criteria 2.

(B) Criteria 1: One or more deviations above the mean The quarterly DSH payment to hospitals eligible under criteria 1 is the sum of Diagnosis Related Groups (DRG) weights for paid Title XIX non-Medicare claims for the quarter multiplied by a percentage of the hospital-specific Unit Value; this determines the hospital's DSH payment for the current quarter. The Unit Value used for eligible Type A, Type B, and Critical Access Hospitals is set at the same rate as for out-of-state hospitals. The calculation is as follows:

(i) For eligible hospitals more than one standard deviation and less than two standard deviations above the mean, the disproportionate share percentage is 5%. The total of all relative weights is multiplied by the hospital's unit value. This amount is multiplied by 5% to determine the DSH payment;

(ii) For eligible hospitals more than two and less than three standard deviations above the mean, the percentage is 10%. The total of all relative weights is multiplied by the hospital's unit value. The amount is multiplied by 0.10 to determine the DSH payment.

(iii) For eligible hospitals more than three standard deviations above the mean, the percentage is 25%. The total of all relative weights is multiplied by the hospital's unit value. This amount is multiplied by 0.25 to determine the DSH payment.

(C) Eligibility under Criteria 2: For hospitals eligible under Criteria 2 (low income utilization rate), the payment is the sum of DRG weights for claims paid by the Division in the quarter, multiplied by the hospital's disproportionate share adjustment percentage established under Section 1886(d)(5)(F)(iv) of the Social Security Act multiplied by the hospital's unit value;

(D) For out-of-state hospitals, the quarterly DSH payment is 5% of the out-of-state unit value multiplied by the sum of the Oregon Medicaid DRG weights for the quarter. Out-of-state hospitals that have entered into agreements with the Division for payment are reimbursed according to the terms of the agreement or contract.

(d) Public Academic Medical Center Disproportionate Share adjustments:

(A) Public academic medical centers that meet the following eligibility standards shall be deemed eligible for additional DSH payments up to 100% of their cost for serving Medicaid fee for service clients and indigent and uninsured patients:

(i) The hospital must have at least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals who are entitled to medical assistance for such services; and

(ii) The hospital must be located within the State of Oregon (border hospitals are excluded); and

(iii) The hospital provides a major medical teaching program, defined as a hospital with more than 200 residents or interns.

(B) 100% of the costs for hospitals qualifying for this DSH payment will be determined from the following sources:

(i) The most recent Medicare Cost Reports; or

(ii) The Division’s record of payments made during the same reporting period; or

(iii) Hospital provided official records from state and county agencies of any cash subsidies paid to the hospital during the same reporting period; or

(iv) Any information which the Division, working in conjunction with representatives of Oregon hospitals, determines necessary to establish cost.

(e) Additional Disproportionate Adjustments:

(A) For all hospitals with a Medicaid utilization rate above one percent of all payer utilization, the DSH payment is the ratio of the hospital’s low income shortfall to the low income shortfall for all eligible hospitals multiplied by the total Federal disproportionate share allotment remaining after disproportionate payments have been made.

(B) The low income shortfall is the Medicaid costs for inpatient and outpatient hospitals services plus uncompensated care for the uninsured cost for inpatient and outpatient hospital services less total Medicaid and self-pay payments for inpatient and outpatient hospital services.

(f) Disproportionate-share payment schedule:

(A) Hospitals qualifying for DSH payments under section (3)(c) above will receive quarterly payments based on claims paid during the preceding quarter. Hospitals that were eligible during one fiscal year but are not eligible for disproportionate share status during the next fiscal year will receive DSH payments based on claims paid in the quarter in which they were eligible. Hospitals qualifying for DSH payments under section (3)(e) above will receive quarterly payments of 25 percent of the amount determined under this section;

(B) Effective October 1, 1994, and in accordance with the Omnibus Budget Reconciliation Act of 1993, DSH payments to hospitals will not exceed 100 percent of the "basic limit" which is:

(i) The inpatient and outpatient costs for services to Medicaid patients, less the amounts paid by the State under the non-DSH payment provisions of the State plan, plus

(ii) The inpatient and outpatient costs for services to uninsured indigent patients, less any payments for such services. An uninsured indigent patient is defined as an individual who has no other resources to cover the costs of services delivered. The costs attributable to uninsured patients are determined through disclosures in the Medicare (HCFA-2552) cost report and state records on indigent care.

(C) The State has a contingency plan to assure that disproportionate share hospital payments will not exceed the State disproportionate share hospital allotment (allotment). A reduction in payments in proportion to payments received will be effected to meet the requirements of section 1923(f) of the Social Security Act. DSH payments are made quarterly. Before payments are made for the last quarter of the Federal fiscal year, payments for the first three quarters and the anticipated payment for the last quarter are cumulatively compared to the allotment.

(i) If the allotment will be exceeded, the DSH payments for the last quarter will be adjusted proportionately for each hospital qualifying for payments under section (3)(d).

(ii) If the allotment will still be exceeded after this adjustment, DSH payments to out-of-state hospitals will be adjusted in proportion to DSH payments received during the previous three quarters.

(iii) If this second adjustment still results in the allotment being exceeded, hospitals qualifying for payments under section (3)(c) (Criteria 1 and 2) will be adjusted by applying each hospital's proportional share of payments during the previous three quarters to total DSH payments to all hospitals for that period.

(D) Similar monitoring, using a predetermined limit based on the most recent audited costs, and including the execution of appropriate adjustments to DSH payments are in effect to meet the hospital specific limit provisions detailed in section 1923(g) of the Social Security Act.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 23-1998, f. & cert. ef. 7-15-98
OMAP 6-1998(Temp), f. & cert. ef. 2-11-98 thru 7-15-98
HR 24-1995, f. 12-29-95, cert. ef. 1-1-96
HR 36-1993, f. & cert. ef. 12-1-93
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0940
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0620
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
AFS 60-1982, f. & cert. ef. 7-1-82; Renumbered from 461-015-0120(5)
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0155 Upper Limits on Payment of Hospital Claims

(1) Supplemental payments:

(a) Private Hospital Supplemental Payments:

(A) From the private Upper Payment Limit (UPL) gap, payments shall be made to all private Diagnosis Related Groups (DRG) hospitals in the form of a per discharge payment applied to hospital specific Medicaid fee-for-service discharges from the quarter preceding the month of the payment;

(B) This payment will be equal to one quarter of the gap amount divided by the total private DRG hospital Medicaid fee-for-service discharges from the quarter proceeding the month of payment;

(b) Non-State Government Owned Hospital Supplemental Payments:

(A) From the non-state government owned hospital upper payment limit gap, payments shall be made to all non-state government owned DRG hospitals in the form of a per discharge payment applied to hospital specific Medicaid fee-for-service discharges from the quarter preceding the month of the payment;

(B) This payment will be equal to one quarter of the gap amount divided by the total non-state government owned DRG hospital Medicaid fee-for-service discharges from the quarter proceeding the month of payment;

(C) The supplemental payments for non-state government owned Hospitals will not exceed the UPL for inpatient hospital services.

(2) For Type A, Type B and Critical Access Hospitals, reimbursement shall be limited to the lesser of allowable costs or billed charges. This limitation shame be applied separately to inpatient and outpatient services.

(3) Payments will not exceed final approved plan:

(a) Total reimbursements to a state-operated facility made during the Division of Medical Assistance Program (Division) fiscal year (July 1 through June 30) may not exceed any limit imposed under federal law in the final approved plan;

(b) Total aggregate inpatient and outpatient reimbursements to all hospitals made during the Division’s fiscal year (July 1 through June 30) may not exceed any limit imposed under federal law in the final approved plan.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
HR 36-1993, f. & cert. ef. 12-1-93
HR 53-1991, f. & cert. ef. 11-18-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91

Or. Admin. R. 410-125-0162 Hospital Transformation Performance Program

(1) The Hospital Transformation Performance Program (HTPP) is established by the Oregon Health Authority (Authority) to allow hospitals to earn incentive payments by meeting specific performance standards that advance health systems transformation, reduce hospital costs, and improve patient safety.

(a) The total amount of funds available through the program is equal to the federal financial participation received from one-percentage point of the assessment. Hospitals that pay an assessment on their net patient revenue, as required by OAR 410-050-0870, are eligible to participate.

(b) The performance standards shall be established by the Authority based on recommendations of the Hospital Performance Advisory Committee (Committee) and as approved by the Centers for Medicare and Medicaid Services (CMS). The Committee shall be appointed by the Authority director and comprise four hospital representatives, two Coordinated Care Organization (CCO) representatives, and three members with expertise in measuring health outcomes.

(2) To qualify for incentive payments, eligible hospitals must meet the performance standards and measures as determined by the Authority.

(3) The Authority will:

(a) Establish baselines and targets for performance measures;

(b) Post the data specs and formats, forms to be used, schedule and frequency of data submission, frequency of incentive distributions, and other technical information on the Authority’s website once determined;

(d) Determine if hospitals achieve targeted goals or demonstrate sufficient improvement to qualify for incentive payments; and

(e) Distribute incentive payments to performing hospitals.

History

Statutory/Other Authority: 2013 OL Ch. 608, Sec. 1, 13 & 25
Statutes/Other Implemented: ORS 414.065 & 2013 OL Ch. 608, Sec. 1, 13 & 25
DMAP 59-2014, f. 10-3-14, cert. ef. 10-7-14

Or. Admin. R. 410-125-0165 Transfers and Reimbursement

(1) When a patient is transferred between hospitals, the transferring hospital is paid on the basis of the number of inpatient days spent at the transferring hospital multiplied by the per diem inter-hospital transfer payment rate.

(2) The per diem inter-hospital transfer payment rate = the DRG payment divided by the geometric mean length of stay for the DRG. The geometric mean length of stay is reported in the DRG tables on the Division’s website.

(3) Payment to the transferring hospital will not exceed the DRG payment.

(4) The final discharging hospital receives the full DRG payment.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 53-1991, f. & cert. ef. 11-18-91
HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0480
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0390
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0135
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 44-1985, f. & ef. 7-1-85

Or. Admin. R. 410-125-0170 Death Occurring on Day of Admission

A hospital receiving DRG reimbursements will receive the DRG reimbursement for the inpatient stay when death occurs on the day of admission as long as at least one hospital benefit day is available.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0840
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 3-1991, f. & cert. ef. 1-4-91
HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570
HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0175 Hospitals Providing Specialized Outpatient Services

Some hospitals provide specific highly specialized outpatient services by arrangement with the Division. Reimbursement is made according to the terms of a written agreement or contract.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 53-1991, f. & cert. ef. 11-18-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91

Or. Admin. R. 410-125-0180 Public Rates

Rates billed to Division of Medical Assistance Programs cannot exceed the facility’s public billing rate.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0240
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0015
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 1-1984, f. & ef. 1-9-84
AFS 37-1983(Temp), f. & ef. 7-15-83
AFS 51-1982, f. 5-28-82, ef. 6-30-82
AFS 30-1982, f. 4-26-82, ef. 5-1-82
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-0181 Non-Contiguous and Contiguous Area Out-of-State Hospitals — Outpatient Services

Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Contiguous area hospitals are out-of-state hospitals located less than 75 miles outside the Oregon border. Unless such hospitals have an agreement with the Agency of Medical Assistance Programs (Agency) regarding reimbursement for specialized services, these hospitals shall be reimbursed as follows:

(1) Laboratory, diagnostic and therapeutic radiology, nuclear medicine, CT scans, MRI services, other imaging services, and maternity case management services shall be reimbursed under an Agency fee schedule.

(2) All other outpatient services shall be reimbursed at 50 percent of billed charges. There is no cost settlement.

(3) Notwithstanding subsection (2) of this rule, this subsection becomes effective for dates of service on and after January 1, 2025. Unless such hospitals have an agreement with the Agency regarding reimbursement for specialized services, these hospitals shall be reimbursed as follows:

(a) Out-of-state contiguous and non-contiguous hospitals are reimbursed at an APC methodology as outlined in 3(b)-(f)

(b) Out-of-state contiguous and non-contiguous reimbursement methodology for hospitals shall be calculated using the wage index and outlier parameters set at the 50th percentile of Oregon hospitals.

(c) The Agency shall grandfather a reimbursement of 50 percent of the 2024 hospital-specific charge master in lieu of the calculation in section 3(b) of this rule, if such payment is requested by the hospital. Supporting documentation shall be required for this process.

(d) Clinical laboratory services shall be reimbursed under an Agency fee schedule;

(e) There shall be no cost settlement for out-of-state contiguous and non-contiguous outpatient services.

(f) The reimbursement for out-of-state contiguous and non-contiguous hospitals will be 80% of Medicare.

(4) The National Drug Code (NDC) must be included on the electronic (837I) and paper (UB 04) claims for physician administered drug codes required by the Deficit Reduction Act of 2005.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 55-2025, amend filed 06/26/2025, effective 06/29/2025
DMAP 146-2024, temporary amend filed 12/29/2024, effective 01/01/2025 through 06/29/2025
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 27-2004, f. 4-22-04, cert. ef. 5-1-04
OMAP 16-2004(Temp), f. & cert. ef. 3-15-04 thru 8-15-04
OMAP 90-2003, f. 12-30-03, cert. ef. 1-1-04
OMAP 58-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 13-2003, f. 2-28-03, cert. ef. 3-1-03
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0780
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0540
HR 18-1990(Temp), f. 6-29-90, cert. ef 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
AFS 60-1982, f. & cert. ef. 7-1-82
Renumbered from 461-015-0120(5)
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0190 Outpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals

(1) The Office of Rural Health designates Type A, Type B, and Critical Access Oregon Hospitals.

(2) Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered outpatient services is as follows:

(a) Interim reimbursement for outpatient covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except laboratory, diagnostic and therapeutic radiology, nuclear medicine, CT scans, MRI services, other imaging services, and maternity case management services which are based on the Division of Medical Assistance Programs (Division) fee schedule;

(b) Retrospective cost-based reimbursement is made for all Fee-For-Service covered outpatient services during the annual cost settlement period;

(c) Cost-based reimbursement is derived from the most recent audited Medicare Cost Report and adjusted to reflect Medicaid mix of services.

(3) Notwithstanding subsection (2) of this rule, this subsection becomes effective for dates of service on and after January 1, 2006, but will not be operative as the basis for payments until the Division determines all necessary federal approvals have been obtained. Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered outpatient services is as follows:

(a) Interim reimbursement for outpatient covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except clinical laboratory, which are based on the Division’s fee schedule;

(b) Retrospective cost-based reimbursement is made for all fee-for-service covered outpatient services during the annual cost settlement period;

(c) Cost-based reimbursement is derived from the most recent audited Medicare Cost Report and adjusted to reflect Medicaid mix of services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
HR 36-1993, f. & cert. ef. 12-1-93
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0780 & 410-125-0800
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0540 & 461-015-0550
HR 18-1990(Temp), f. 6-29-90, cert. ef 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0195 Outpatient Services In-State DRG Hospitals

(1) The National Drug Code (NDC) must be included on all claim formats for physician administered drug codes required by the Deficit Reduction Act of 2005.

(2) For discharges prior to January 1, 2012, In-State Diagnostic Related Grouper (DRG) hospital outpatient and emergency services are reimbursed under a cost-based methodology.

(a) Interim reimbursement:

(A) The interim reimbursement percentage is developed using the cost-to-charge ratio methodology, derived from the Medicare cost report, and applied to billed charges;

(B) The interim payment is the estimated percentage needed to achieve 100 percent of hospital cost in aggregate; and

(C) This interim percentage is applied to all outpatient charges except for clinical laboratory services. Interim reimbursement for clinical laboratory services is calculated according to rates published in the Agency fee schedule.

(b) Settlement reimbursement:

(A) For Medicaid and Children’s Health Insurance Program-eligible (Titles XIX and XXI of the Social Security Act) clients, an adjustment to 100 percent of outpatient costs is made during the cost settlement process;

(B) For General Assistance (GA) clients, outpatient hospital services are reimbursed at 50 percent of billed charges or 59 percent of costs, whichever is less.

(3) Effective for discharges on or after January 1, 2012:

(a) In-State DRG hospital outpatient and emergency services shall be reimbursed in accordance with Code of Federal Regulations 42 Part 419 Prospective Payment System for Hospital Outpatient Department Services, using the Ambulatory Payment Classification (APC) Group methodology, and

(b) Payments shall be based on rates determined by State Actuarial Services to be equivalent to 100 percent of Medicare outpatient payments for each DRG hospital.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 90-2025, amend filed 12/17/2025, effective 12/17/2025
DMAP 59-2025, temporary amend filed 07/30/2025, effective 08/01/2025 through 01/27/2026
DMAP 55-2025, amend filed 06/26/2025, effective 06/29/2025
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
DMAP 48-2011(Temp), f. 12-23-11, cert. ef. 1-1-12 thru 6-25-12
DMAP 31-2009, f. 9-22-09, cert. ef. 10-1-09
DMAP 10-2009(Temp), f. 4-29-09, cert. ef. 5-1-09 thru 10-28-09
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 43-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 21-2005, f. 3-21-05, cert. ef. 4-1-05
OMAP 78-2004(Temp), f. & cert. ef. 10-1-04 thru 3-15-05
OMAP 90-2003, f. 12-30-03, cert. ef. 1-1-04
OMAP 37-2003, f. & cert. ef. 5-1-03
OMAP 16-2003(Temp), f. & cert. ef. 3-10-03 thru 8-1-03
OMAP 13-2003, f. 2-28-03, cert. ef. 3-1-03
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 36-1993, f. & cert. ef. 12-1-93
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0780 & 410-125-0800
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0540 & 461-015-0550
HR 18-1990(Temp), f. 6-29-90, cert. ef 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0200 Time Limitation for Submission of Claims

Division of Medical Assistance Programs (Division) will accept a claim up to 12 months after the date of service. The date of discharge is the date of service for an inpatient hospital claim.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 42-1991, f. & cert. ef. 10-1-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0250
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0201 Independent ESRD Facilities

(1) Independent End Stage Renal Dialysis (ESRD) Facilities:

(a) ESRD facilities are reimbursed for Continuous Ambulatory Peritoneal Dialysis.

(b) (CAPD), Continuous Cycling Peritoneal Dialysis (CCPD), and Hemodialysis:

(A) Composite at 80% of the Medicare allowed amount, except for Epoetin.

(B) Epoetin is reimbursed at 100% of the Medicare maximum allowed amount.

(2) Other dialysis related charges which are allowed by Medicare, are reimbursed at 80% of the Medicare maximum allowed amount. Allowable clinical laboratory charges are reimbursed according to the Division’s fee schedule. Billed charges may not exceed the Medicare maximum allowable amount.

(3) The Division follows Medicare's criteria for coverage of Epoetin, Intradialytic Parenteral Nutrition services, and the frequency schedule for laboratory tests for ESRD services. When laboratory tests are performed at a frequency greater than specified by Medicare, the additional tests must be billed separately, and are covered by the Division only if the tests are medically justified by accompanying documentation. A diagnosis of ESRD alone is not sufficient medical evidence to warrant coverage of the additional tests.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0820
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0560
HR 9-1990(Temp), f. 3-30-90, cert. ef. 4-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0210 Third Party Resources and Reimbursement

(1) The Division of Medical Assistance Programs (Division) establishes maximum allowable reimbursements for all services. When clients have other third party payers, the payment made by that payer is deducted from the Division’s maximum allowable payment.

(2) The Division will not make any additional reimbursement when a third party pays an amount equal to or greater than the Division’s reimbursement. The Division will not make any additional reimbursement when a third party pays 100 percent of the billed charges, except when Medicare Part A is the primary payer.

(3) When Medicare is Primary:

(a) The Division’s calculates the reimbursement for these claims in the same manner as described in the Inpatient and Outpatient Rates Calculations Sections above;

(b) Payment is the Division allowable payment, less the Medicare payment, up to the amount of the deductible and/or coinsurance due. For clients who are Qualified Medicare Beneficiaries the Division does not make any reimbursement for a service that is not covered by Medicare. For clients who are Qualified Medicare/Medicaid Beneficiaries Division payment is the Division’s allowable, less the Part A payment up to the amount of the deductible due for services by either Medicare or Medicaid.

(4) When Medicare is Secondary:

(a) An individual admitted to a hospital may have Medicare Part B, but not Part A. The Division calculates the reimbursement for these claims in the same manner as described in the Inpatient Rates Calculations section above. Payment is the Division’s allowable payment, less the Medicare Part B payment;

(b) An individual receiving services in the outpatient setting may have most services covered by Medicare Part B. The Division payment is the Division’s allowable payment, less the Part B payment, up to the amount of the coinsurance and deductible due. For services provided in the outpatient setting which are not covered by Medicare, (for example, Take Home Drugs), the Division payment is the Division’s allowable payment as calculated in the Outpatient Rates Calculation section above;

(c) Most Medicare-Medicaid clients have Medicare Part A, Part B, and full Medicaid coverage. The Division refers to these clients as Qualified Medicare-Medicaid Beneficiaries (QMM). However, a few individuals have Medicare coverage and only limited additional coverage through Medicaid. the Division refers to these clients as Qualified Medicare Beneficiaries (QMB). For QMB clients, the Division does not make reimbursement for a service that is a not covered service for Medicare.

(d) Clients who are Qualified Medicare-Medicaid Beneficiaries will have coverage for services that are not covered by Medicare if those services are covered by the Division.

(5) For clients with Physician Care Organization (PCO) or Prepaid Health Plan (PHP) Coverage, Division payment is limited to those services that are not the responsibility of the PCO or PHP. Payment is made at Division rates.

(6) Other Insurance:

(a) The Division pays the maximum allowable payment as described in the Inpatient and Outpatient Rates Calculations, less any third party payments;

(b) The Division will not make additional reimbursements when a third party payor (other than Medicare) pays an amount equal to or greater than the Division reimbursement, or 100 percent of billed charges.

(7) Medically Needy with Spend-Down. Reimbursement is the Division’s maximum allowable payment for covered services less the amount of the spend-down due.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-1000
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0640
HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0056
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 1-1984, f. & ef. 1-9-84
AFS 37-1983(Temp), f. & ef. 7-15-83
AFS 60-1982, f. & ef. 7-1-82
AFS 57-1980, f. 8-29-80, ef. 9-1-80
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-0220 Temporary rule language in effect until 12/27/2026. Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms

(1) All inpatient and outpatient services provided by the hospital or hospital employees, unless otherwise specified below, are billed on the electronic 837I (837 Institutional) or on the paper CMS 1450 (UB-04) claim form.

(2) Professional staff and other providers: Services provided by other providers or professional staff with whom the hospital has a contract or agreement regarding provision of services and whom the hospital reimburses a salary or a fee are billed on the electronic 837I or paper CMS 1450 (UB-04) along with other inpatient or outpatient charges if such costs are reported on the hospital's Medicare Cost Report as a hospital cost.

(3) Residents and medical students: Professional services provided by residents or medical students serving in the hospital as residents or students at the time services are provided are reimbursed by the Oregon Health Authority in accordance with the medical education reimbursement rates identified in OAR 410-125-0141 so long as the hospital where the residents and medical students work qualify for those payments. The services provided by residents and medical students that are paid the rates identified in OAR 410-125-0141 must not be billed on the electronic 837I or paper CMS 1450 (UB-04).

(4) Diagnostic and similar services provided by another provider or facility outside the hospital: When diagnostic or short-term services are provided to an inpatient by another provider or facility because the admitting hospital does not have the equipment or facilities to provide all services required and the patient is returned within 24 hours to the admitting hospital, the admitting hospital should add the following charges to the inpatient electronic 837I or paper CMS 1450 (UB-04) claim:

(a) Charges from the other provider or hospital under the appropriate Revenue Code. The admitting hospital is responsible for reimbursing the other provider or hospital. The Division will not reimburse the other provider or hospital; and

(b) Charges for transportation to the other facility or provider. These must be billed under Revenue Code 542. No prior authorization of the transport is required. The hospital will arrange for the transport and pay the transportation provider for the transport. The Division will not reimburse the transportation provider. This is the only instance in which transportation charges can be billed on the electronic 837I or paper CMS 1450 (UB-04).

(5) Orthotics, prosthetics, durable medical equipment and implants:

(a) When a provider of orthotic or prosthetic devices provides services or materials to an inpatient through an agreement or arrangement with the hospital, the cost of those services will be billed by the hospital on the electronic 837I or the paper CMS 1450 (UB-04), along with all other inpatient services. The hospital is responsible for reimbursing the provider. The Division will not reimburse the provider;

(b) Wheelchairs provided to the client for the client's use after discharge from the hospital may be billed separately by the durable medical equipment supplier or by the hospital if the hospital is the supplier.

(6) Pharmaceutical and home parenteral/enteral services: All hospital pharmaceutical charges must be billed on the electronic 837I or paper UB-04, except home parenteral and enteral services and medications provided to patients who are in nursing homes:

(a) Home parenteral and enteral services, including home hyperalimentation, Home IV antibiotics, home IV analgesics, home enteral therapy, home IV chemotherapy, home IV hydrational fluids, and other home IV drugs, require prior authorization and must be billed on the Pharmacy Invoice Form in accordance with the rules in the Home Enteral/Parenteral Program rules (chapter 410, division 148);

(b) Medications provided to clients who are in nursing homes must be billed on the Pharmacy Invoice Form in accordance with the rules in the Pharmaceutical Services Program rules (chapter 410, division 121).

(7) Dental services: Dental services provided by hospitals are billed on the electronic 837I or paper CMS 1450 (UB-04). For hospital dentistry requirements refer to the Dental Service Program rules (chapter 410, division 123).

(8) End-stage renal dialysis facilities: Hospitals providing end-stage renal dialysis and free-standing end-stage renal dialysis facilities will bill on the electronic 837I or paper CMS 1450 (UB-04) as described in these rules and instructions and will be reimbursed at the hospital's interim rate.

(9) Maternity case management:

(a) Hospital clinics may serve as maternity case managers for pregnant clients. The Medical-Surgical Program rules (chapter 410, division 130) contain information on the scope of services, definition of program terms, procedure codes, and provider qualifications. These services are billed by hospitals on the electronic 837I or paper CMS 1450 (UB-04); and

(b) Providers must bill using Revenue Code 569.

(10) Home health care services. Hospitals that operate home health care services must obtain a separate provider number and bill for these services in accordance with the Division’s Home Health Care Services Program rules (chapter 410, division 127).

(11) Hospital operated air and ground ambulance services. A hospital which operates an air or ground ambulance service may apply to the Division for a provider number as an air or ground ambulance provider. If costs for staff and equipment are reported on the Medicare Cost Report, these costs must be identifiable. The Division will remove these costs from the Medicare Cost Report in calculating the hospital's cost-to-charge ratio for outpatient services. These services are billed on the electronic 837P (837 Professional) claim form or the paper CMS-1500 in accordance with the rules and restrictions contained in the Medical Transportation Program rules (chapter 410, division 136).

(12) Supervising physicians providing services in a teaching setting:

(a) Services provided on an inpatient or outpatient basis by physicians who are on the faculty of teaching hospitals may be billed on the electronic 837I or paper CMS 1450 (UB-04) with other inpatient or outpatient charges only when:

(A) The physician is serving as an employee of the hospital, or receives reimbursement from the hospital for provision of services, during the period of time when services are provided; and

(B) The hospital does not report these services as a direct medical education cost on the Medicare and the Division’s cost report.

(b) The services of supervising faculty physicians are not to be billed to the Division on either the electronic 837P, the paper CMS-1500 or the electronic 837I or paper CMS 1450 (UB-04) if the hospital elects to report the cost of these professional services as a direct medical education cost on the Medicare and the Division’s cost report; and

(c) The services of supervising faculty physicians are billed on the electronic 837P or the paper CMS-1500 if the physician is serving in a private capacity during the period of time when services are provided, i.e., the physician is receiving no reimbursement from the hospital for the period of time during which services are provided. Refer to the Medical-Surgical Services rules (chapter 410, division 130) for additional information on billing on the electronic 837P or the paper CMS-1500.

(13) Caring Contacts services in a hospital setting: Caring contacts services are provided to clients as described in OAR 333-520-0070.

(a) For purposes of billing under this rule, the caring contact must:

(A) Be made within 48 hours after a patient has been discharged from a hospital after presenting to the Emergency Department with a behavioral health crisis (as defined by ORS 441.053); and

(B) A qualified mental health professional or a registered nurse meeting the competency and training requirements identified in 333-520-0070(4)(g)(A) determined the patient’s behavioral health crisis involved attempted suicide or an experience of suicidal ideation.

(b) The hospital may:

(A) Provide the caring contacts services in person, by phone, or via telehealth;

(B) Contract with a qualified community based behavioral health provider for the provision of these services; or

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 24-2026, temporary amend filed 06/24/2026, effective 07/01/2026 through 12/27/2026
DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 13-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
HR 4-1995, f. & cert. ef. 3-1-95
HR 5-1994, f. & cert. ef. 2-1-94
HR 36-1993, f. & cert. ef. 12-1-93
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0280, 410-125-0300, 410-125-0320, 410-125-0340, 410-125-0540 & 410-125-0560
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0055, 461-015-0130, 461-015-0135
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 38-1986, f. 4-29-86, ef. 6-1-86
AFS 52-1985, f. 9-3-85, ef. 10-1-85
AFS 44-1985, f. & ef. 7-1-85
AFS 29-1985, f. 5-22-85, ef. 5-29-85
AFS 48-1984(Temp), f. 11-30-84, ef. 12-1-84
AFS 45-1984, f. & ef. 10-1-84
AFS 1-1984, f. & ef. 1-9-84
AFS 37-1983(Temp), f. & ef. 7-15-83
AFS 51-1982, f. 5-28-82, ef. 6-30-82
AFS 30-1982, f. 4-26-82, ef. 5-1-82
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-0221 Payment in Full

The payment made by Medicaid towards any inpatient or outpatient services, including cost outlier, disproportionate share, and capital payments, constitutes payment in full for the service.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0840
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 3-1991, f. & cert. ef. 1-4-91
HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570
HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0230 Qualified Directed Payments

Qualified Directed Payments (QDP) are payments made by the Oregon Health Authority (Authority) to Coordinated Care Organizations (CCOs) from three Quality and Access pools for distinct provider classes as follows: (i) Rural Type A and Type B hospitals, (ii)Public Academic Health Centers and (iii) DRG hospitals. Each provider class is defined in §438.6(c) Preprint forms approved by the U.S. Department of health and Human Services Centers for Medicare and Medicaid Services. QDPs are tied to inpatient and outpatient encounters with Medicaid and Children's Health Insurance Program (CHIP) members enrolled in Coordinated Care Organizations. However, the Authority does not make Qualified Directed Payments for encounters with members who received Citizenship Waived Medical (CWM) or CWM Plus Benefit Packages.

(1) Type A and Type B hospitals:

(a) The Authority shall make a qualified directed payment only if the Type A or Type B hospital meets criteria established by the Authority for the Type A or Type B hospital Quality and Access program in accordance with applicable federal requirements, which may be updated as needed.

(b) The Authority shall make a qualified directed payment for each inpatient and outpatient encounter; one encounter per member, per day, per facility;

(d) Payment rates shall be set by the Authority and may be adjusted based on actual utilization and available Quality and Access Funds;

(e) The Authority shall create a monthly report to assist CCOs in distributing funds to the appropriate hospital. The report shall be distributed to each CCO and each Type A and Type B hospital;

(f) Within five (5) business days after receipt of the monthly report, the CCO shall submit an electronic payment to an account established by the hospital for the amount indicated on the report;

(g) Adjustments shall be processed weekly through the Medicaid payment system and included in the monthly report.

(2) Public Academic Health Centers:

(a) The Authority shall make a qualified directed payment only if the public academic medical center meets criteria established by the Authority for the Public Academic Medical Center Quality and Access program in accordance with applicable federal requirements, which may be updated as needed.

(b) The Authority shall make a qualified directed payment for each inpatient and outpatient encounter; one encounter per member, per day, per facility;

(d) Payment rates shall be set by the Authority and may be adjusted based on actual utilization and available Quality and Access Funds;

(e) The Authority shall combine the weekly encounters into a monthly report to assist CCOs in distributing the funds to the appropriate hospital. The report shall be distributed to each CCO and public academic health center;

(f) Within five (5) business days after receipt of the monthly report, the CCO shall submit an electronic payment to an account established by each public health center for the amount indicated on the report;

(g) Adjustments shall be processed weekly through the Medicaid payment system and included in the monthly report.

(3) Diagnosis Related Grouper (DRG) Hospitals:

(a) The Authority shall make a qualified directed payment only if the DRG Hospital meets criteria established by the Authority for the DRG Hospital Quality and Access Pool program in accordance with applicable federal requirements, which may be updated as needed.

(b) The Authority shall make a qualified directed payment for each inpatient and outpatient encounter; one encounter per member, per day, per facility;

(d) Payment rates shall be set by the Authority and may be adjusted based on actual utilization and available Quality and Access Funds;

(e) The Authority shall create a monthly report to assist CCOs in distributing funds to the appropriate hospital. The report shall be distributed to each CCO and each DRG hospital;

(f) Within five (5) business days after receipt of the monthly report, the CCO shall submit an electronic payment to an account established by the hospital for the amount indicated on the report;

(g) Adjustments shall be processed weekly through the Medicaid payment system and included in the monthly report.

(4) If an error is identified in the monthly report, the CCO shall make the payment based on the original amount provided in the report. The Authority shall identify separately the correction in the following month's report and adjust the total payment amount to account for the error.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.869
Statutes/Other Implemented: ORS 414.869
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 52-2019, amend filed 12/12/2019, effective 01/01/2020
DMAP 64-2017, adopt filed 12/29/2017, effective 01/01/2018

Or. Admin. R. 410-125-0360 Definitions and Billing Requirements

(1) Total days on an inpatient claim must equal the number of accommodation days. Do not count the day of discharge when calculating the number of accommodation days.

(2) Inpatient services are reimbursed based on the admission date and discharge diagnosis.

(3) Inpatient services are services to patients who typically are admitted to the hospital before midnight and listed on the following day's census, with the following exceptions:

(a) A patient admitted and transferred to another acute care hospital on the same day is considered an inpatient;

(b) A patient who expires on the day of admission is an inpatient; and

(4) Outpatient services:

(a) Outpatient services are services to patients who are treated and released the same day;

(b) Outpatient services also include services provided prior to midnight and continuing into the next day if the patient was admitted for ambulatory surgery, admitted to a birthing center, a treatment or observation room, or a short term stay bed;

(c) Outpatient observation services are services provided by a hospital, including the use of a bed and periodic monitoring by hospital nursing or other staff for the purpose of evaluation of a patient's medical condition. A maximum of 48 hours of outpatient observation shall be reimbursed. An outpatient observation stay that exceeds 48 hours shall be billed as inpatient; and

(d) Outpatient observation services do not include the following:

(A) Services provided for the convenience of the patient, patient's family or physician but that are not medically necessary;

(B) Standard recovery period; and

(5) Outpatient and inpatient services provided on the same day: If a patient receives services in the emergency room or in any outpatient setting and is admitted to an acute care bed in the same hospital on the same day, combine the emergency room and other outpatient charges related to that admission with the inpatient charges. Bill on a single UB-04 for both inpatient and outpatient services provided under these circumstances:

(a) If on the day of discharge, the client uses outpatient services at the same hospital, these shall be billed on the UB-04 along with other inpatient charges, regardless of the type of service provided or the diagnosis of the client. Prescription medications provided to a patient being discharged from the hospital may be billed separately as outpatient Take Home Drugs if the patient receives more than a three-day supply;

(b) Inpatient and outpatient services provided to a client on the same day by two different hospitals shall be reimbursed separately. Each hospital shall bill for the services provided by that hospital;

(c) Inpatient and psychiatric emergency services (PES) as defined in OAR 309-023-0110 provided to the patient on the same day, whether in the same hospital or two different hospitals, shall be reimbursed separately.

(6) Outpatient procedures that result in an inpatient admission: If, during the course of an outpatient procedure, an emergency develops requiring an inpatient stay, place a "1" in the Type of Admission field. The principal diagnosis should be the condition or complication that caused the admission. Bill charges for the outpatient and inpatient services together.

[ED. NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 77-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 63-2016(Temp), f. & cert. ef. 11-10-16 thru 5-8-17
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 4-1995, f. & cert. ef. 3-1-95
HR 36-1993, f. & cert. ef. 12-1-93
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0380 & 410-125-0460
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0330, 461-015-0340 & 461-015-0380
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0055
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 38-1986, f. 4-29-86, cert. ef. 6-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 29-1985, f. 5-22-85, cert. ef. 5-29-85
AFS 48-1984(Temp), f. 11-30-84, cert. ef. 12-1-84
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983 (Temp), f. & cert. ef. 7-15-83
AFS 51-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 30-1982, f. 4-26-82, cert. ef. 5-1-82
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-0400 Discharge

(1) A discharge from a hospital is the formal release of a patient to home, to another facility such as an intermediate care facility or nursing home, to a home health care agency, or to another provider of health care services.

(2) For services beginning January 1, 1993, and later, the transfer of a patient from acute care to a distinct part physical rehabilitation unit (i.e., a unit exempt from the Medicare Prospective Payment System) within the same hospital will be considered a discharge. The admission to the rehabilitation unit is billed separately. All other transfers occurring within a hospital, including transfers to Medicare PPS-exempt psychiatric units, will not be considered discharges, and all charges for services must be submitted on a single UB-04 billing for the admission.

(3) Transfer from a hospital occurs when an individual is formally released to another acute care hospital, to a long-term acute care hospital, to a skilled nursing facility, or an intermediate care facility. When a physician sends a patient directly to another hospital for further inpatient care, the discharge should be billed as a transfer, regardless of the mode of transportation.

(4) When the Division receives claims from two hospitals for the same patient, and the date of discharge from one hospital is the same as the date of admission to the other, the Division will assume that a transfer has occurred. The Division will change the discharge status code on the first claim to 02 (Transferred to Another Acute Care Facility), automatically generating an adjustment if the claim has already been adjudicated, unless discharge status on the claim is already 02 (Transfer) or 07 (Discharge AMA). If it is believed that the Division made an error in assigning Discharge Status code 02 to a claim, the hospital may submit an Adjustment Request along with supporting documentation from the medical record.

(5) A transfer between units within a hospital is not a transfer for billing purposes, except in the case of transfers to distinct part physical rehabilitation units. Note that transfers in the other direction from rehabilitative care to acute care are not considered discharges from the rehabilitation unit unless the stay in the acute setting exceeds seven days. Stays of seven days or less in the acute care setting may not be billed separately.

(6) Some transfers, including transfers to distinct part rehabilitation units, require prior authorization.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 31-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
HR 36-1993, f. & cert. ef. 12-1-93
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 42-1991, f. & cert. ef. 10-1-91
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0401 Definitions: Emergent, Urgent, and Elective Admissions

(1) EMERGENT ADMISSION — an admission which occurs after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:

(a) Placing their health or the health of an unborn child in serious jeopardy;

(b) Serious impairment of bodily functions; or

(c) Serious dysfunction of any bodily organ or part. "Immediate medical attention" is defined as medical attention which could not be delayed by 24 hours.

(2) URGENT ADMISSION — an admission which occurs for evaluation or treatment of a medical disorder that could become an emergency if not diagnosed or treated in a timely manner; that delay is likely to result in prolonged temporary impairment; and that unwarranted prolongation of treatment increases the risk of treatment by the need for more complex or hazardous treatment or the risk of development of chronic illness or inordinate physical or psychological suffering by the patient. An urgent admission is defined as one which could not have been delayed for a period of 72 hours.

(3) ELECTIVE ADMISSION — an admission which is or could have been scheduled in advance and for which a delay of 72 hours or more in the delivery of medical treatment or diagnosis would not have substantially affected the health of the patient. See Prior Authorization section of the Hospital Services rules for requirements.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0410 Readmission

(1) A patient whose readmission for surgery or follow-up care is planned at the time of discharge must be placed on leave of absence status, and both admissions must be combined into a single billing. The Division of Medical Assistance Programs (Division) will make one payment for the combined service. Examples of planned readmissions include, but are not limited to, situations where surgery could not be scheduled immediately, a specific surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately.

(2) A patient whose discharge and readmission to the hospital is within thirty (30) days for the same or related diagnosis must be combined into a single billing. Division shall make one payment for the amount appropriate for the combined service.

(3) This rule does not apply to:

(a) Readmissions for an unrelated diagnosis;

(b) Readmissions occurring more than 30 days after the date of discharge;

(c) Readmissions for a diagnosis that may require episodic (a series) acute care hospitalizations to stabilize the medical condition such as, but not limited to: diabetes, asthma, or chronic obstructive pulmonary disease. See billing instructions in the Hospital Supplemental guide on the Division’s website for additional information.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 13-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 11-2004, f. 3-11-04, cert. ef. 4-1-04
HR 36-1993, f. & cert. ef. 12-1-93

Or. Admin. R. 410-125-0450 Provider Preventable Conditions

(1) Health Care-Acquired Conditions (HCAC):

(a) Formally known as Medicare’s list of “hospital acquired conditions” (HAC) that apply to inpatient hospital settings with dates of admission on or after January 1, 2011 except those hospitals exempt from the reporting requirements.

(b) For inpatient hospital admissions on or after July 1, 2012, all in-state, contiguous and non-contiguous hospitals must report health care-acquired conditions.

(A) A HCAC is a condition that is reasonably preventable and was not present or identified at the hospital admission.

(B) A “present on admission” (POA) indicator is a status code the hospital uses on an inpatient claim that indicates if a condition was present at the time the order for inpatient admission occurs. A POA indicator can also identify a condition that developed during an outpatient encounter. This includes, but is not limited to the emergency department, observation, and outpatient surgery.

(C) The Division of Medical Assistance Program (Division) shall use the most recent list of conditions identified as non-payable by Medicare. The Division may revise through addition or deletion the selected conditions at any time during the fiscal year.

(D) Diagnosis-related groups (DRG) and percentage paid hospitals must submit a POA indicator for the principal diagnosis and every secondary diagnosis code. A valid POA indicator must be included all inpatient hospital claims. Claims without a valid POA indicator shall be denied.

(E) Critical Access Hospitals (CAH) must implement the POA reporting requirements by September 1, 2013.

(F) For a complete list of HCACs and billing instructions please see the hospital supplemental guide.

(2) Other Provider-Preventable Conditions (OPPC):

(a) Applies to any health care setting, including but not limited to inpatient and outpatient hospital settings.

(b) Effective July 1, 2012 the Agency shall no longer cover the following conditions identified by the National Coverage Determinations (NCD):

(A) Wrong surgical or other invasive procedure performed on a patient;

(B) Surgical or other invasive procedure performed on the wrong body part;

(A) No reduction in payment for a Provider Preventable Conditions (PPC) will be imposed on a provider when an identified PPC for a client existed prior to the initiation of treatment for that client by that provider.

(B) Reductions in provider payment may be limited to the extent that the identified PPC would otherwise result in an increase in payment; and the Division reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to the PPC.

(3) For clients with both Medicare and Medicaid (duals) the agency may not act as secondary payer for Medicare non-payment of HCAC.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 47-2013, f. 8-29-13, cert. ef. 9-3-13
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
Reverted to DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 49-2011(Temp), f. 12-23-11, cert. ef. 1-1-12 thru 6-25-12
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11

Or. Admin. R. 410-125-0550 X-Ray or EKG Procedures Furnished in Emergency Room

The Division pays for only one interpretation of an x-ray or EKG procedure furnished to an emergency room patient, and that is for the interpretation and report that directly contributed to the diagnosis and treatment of the patient. A second interpretation of an x-ray or EKG is considered to be for quality control purposes only, and is not reimbursable. Payment will be made for a second interpretation only under unusual circumstances, such as questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: : ORS 414.065
OMAP 28-2000, 9-29-00, cert. ef. 10-1-00

Or. Admin. R. 410-125-0600 Non-Contiguous Out-of-State Hospital Services

(1) Non-contiguous out-of-state hospitals are those hospitals located more than 75 miles from the Oregon border.

(2) The hospital must be enrolled as a provider with Oregon Medical Assistance Programs to receive payment. Contact the Division of Medical Assistance Programs (Division) for information on enrollment.

(3) Billings are sent to the Division.

(4) When the service provided is emergent or urgent, no prior authorization is required. The claim should be sent to the Division along with documentation supporting the emergent or urgent requirement for treatment.

(5) In a non-emergency situation, prior authorization is required for all services. Contact: the Division.

(6) Claims must be billed on the electronic 837I or on a paper CMS 1450 (UB-04), unless other arrangements are made for billing through the Division.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
HR 36-1993, f. & cert. ef. 12-1-93
HR 42-1991, f. & cert. ef. 10-1-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0450
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-0620 Special Reports and Exams and Medical Records

Refer to the Division’s Administrative Exams and Reports Billing rules (chapter 410 division 150) for information and instructions on billing for administrative exams and reports.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 3-1997, f. 1-31-97, cert. ef. 2-1-97
HR 36-1993, f. & cert. ef. 12-1-93
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0460
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0040
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 60-1982, f. & ef. 7-1-82
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-0640 Third Party Payers — Other Resources, Client Responsibility and Liability

(1) Medicare: Do not send claims to the Division of Medical Assistance Programs (Division) until they have been billed to and adjudicated by Medicare:

(a) Exception: Take home drugs and other services, which are not covered by Medicare, may be billed directly to the Division without billing Medicare first;

(b) See: billing instructions in the Hospital Services Supplemental Information on the Division’s website for additional information on billing Medicare claims.

(2) Other Insurance. With the exception of services described in the General Rules, bill all other insurance first before billing the Division. Report the payments made by the other insurers.

(3) Motor vehicle accident fund:

(a) Enter 01 (Auto Accident) in the Occurrence Code Block and give the date of the accident;

(b) For all other clients, bill all other resources before billing the Division. Do not bill the Motor Vehicle Accident Fund.

(4) Employment Related Injuries: Enter 04 (Employment Related Accident) in the Occurrence Code Block and give the date of the injury.

(5) Liability:

(a) Liability refers to insurance that provides payment based on legal liability for injuries or illness or damages to property. It includes, but is not limited to, automobile liability insurance, uninsured and underinsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance and general casualty insurance. It also includes payments under state "wrongful death" statutes that provide payment for medical damages;

(b) The provider may bill the insurer for liability prior to billing the Division. The provider may not bill both the Division and the insurer;

(c) The provider may bill the Division after receiving a payment denial from the insurer; however, the Division billing must be within 12 months of date of service. Payment accepted from Division is payment in full;

(d) The provider may bill the Division without billing the liability insurer. However, payment accepted from the Division is payment in full. The payment made by the Division may not later be returned in order to pursue payment from the liability insurer. When the provider bills the Division, the provider agrees not to place any lien against the client's liability settlement;

(e) The provider has 12 months from the date of service to bill the Division. No payment will be made by Division under any circumstances once the one year limit has passed if no billing has been received within that time.

(6) Adoption agreements. Adopting parents and/or an adoption agency may be considered a prior resource. In some instances, the Division makes reimbursement to hospitals and other providers for services provided to a mother whose baby is to be adopted. The Division may also make reimbursement for services provided to the infant. Some adoption agreements, however, stipulate that the adoptive parents will make payment for part or all of the medical costs for the mother and/or the child. In these instances, the adoptive parent(s) and/or agency are a third party resource and should be billed before billing the Division for this service.

(7) Veteran's Administration benefits:

(a) Some clients have limited benefits through the Veterans' Administration. Hospitals must bill the Veterans' Administration for VA covered services before billing the Division;

(b) The Veterans' Administration requires notification within 72 hours of an emergency admission to a non-VA hospital.

(8) Trust funds. Some individuals will have trust funds that will pay for medical expenses. Occasionally a special trust fund will be set up to pay for extraordinary medical expenses, such as a transplant. These, and other trusts which pay medical expenses, are considered a prior resource. Bill the trust fund prior to billing the Division for services that are covered by the trust fund.

(9) Billing the client. A provider may bill the client or any financially responsible relative or representative of that individual only as allowed in OAR 410-120-1280.

(10) The hospital may not bill the client under the following circumstances:

(a) For services which are covered by the Division;

(b) For services for which the Division has made payment;

(c) For services billed to the Division for which no payment is made because third party reimbursement exceeds the Division maximum allowed amount;

(d) For any deductible, coinsurance or co-pay amount;

(e) For services for which the Division has denied payment to the hospital as a result of one of the following:

(A) The hospital failed to supply the correct information to the Division to allow processing of the claim in a timely manner as described in these rules and the General Rules;

(B) The hospital failed to obtain prior authorization as described in these rules;

(D) The service provided by the hospital was determined by the QIO not to be medically appropriate, necessary, or reasonable.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
HR 5-1994, f. & cert. ef. 2-1-94
HR 36-1993, f. & cert. ef. 12-1-93
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93
HR 22-1992, f. 7-31-92, cert. ef. 8-1-92
HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0660
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0470 & 461-015-0480
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0080 & 461-015-0126
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 1-1984, f. & ef. 1-9-84
AFS 37-1983(Temp), f. & ef. 7-15-83
AFS 60-1982, f. & ef. 7-1-82
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-0641 Medicare

(1) A Medicare/Medicaid claim can automatically be sent to the Division after adjudicated by Medicare. This saves the effort of a second submission, as well as ensuring a more accurate and speedier payment by the Division. Medicare will automatically transmit the correct Medicare payment, coinsurance, and deductible information to Division.

(2) Hard copy billings sent to Medicare can also be automatically sent to the Division. Refer to the Hospital Services Supplemental Information for specific billing instructions.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 36-1993, f. & cert. ef. 12-1-93
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-0720 Adjustment Requests

(1) Most overpayment and under-payments are resolved through the adjustment process. Only paid claims can be adjusted. If no payment was made, the claim must be submitted using a CMS 1450 (UB-04) for processing. All overpayments must be reported. Overpayments will be taken from future payments.

(2) Much of the information required on the Adjustment Request Form is printed on the paper Remittance Advice or the electronic 835. Documentation may be submitted to support the request. Attach a copy of the claim and paper Remittance Advice or the electronic 835 to the Adjustment Request (Division 1036). Adjustment requests must be submitted in writing to the Division of Medical Assistance Programs (Division).

(3) Complete adjustment instructions can be found in Hospital Services Supplemental Information.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91
HR 2-1991, f. & cert. ef 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0510
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-1020 Filing of Cost Statement

(1) The hospital must file an annual Calculation of Reasonable Cost (DMAP 42), covering the latest fiscal period of operation of the hospital with Division of Medical Assistance Programs (Division):

(a) A Calculation of Reasonable Cost statement is filed for less than an annual period only when necessitated by the hospital's termination of their agreement with the Division, a change in ownership, or a change in the hospital's fiscal period;

(b) The hospital must use the same fiscal period for the Division 42 as that used for its Medicare report. If it doesn't have an agreement with Medicare, the hospital must use the same fiscal period it uses for filing its federal tax return;

(c) The report must be filed for both inpatient and outpatient services, even if the service is paid under a prospective payment system or fee schedule (e.g., Diagnosis-Related Groups (DRG) payments, outpatient clinical laboratory, etc.);

(d) In the absence of an agreement with Medicare, the hospital must use the same fiscal period as that used for filing their Federal tax return.

(2) Twelve months after the hospital's fiscal year end, the Division will send the hospital a computer printout listing all transactions between the hospital and the Division during that auditing period. The Calculation of Reasonable Cost statement (DMAP 42) is due within 90 days of receipt by the hospital of the computer printout. Failure to file within 90 days may result in a 20 percent reduction in the payment rate:

(a) Hospitals without an agreement with Medicare may be subject to a field audit;

(b) Hospitals without an agreement with Medicare are required to submit a financial statement giving details of all assets, liabilities, income, and expenses, audited by a Certified Public Accountant.

(3) Improperly completed or incomplete Calculation of Reasonable Cost statements will be returned to the hospital for proper completion. The statement is not considered to be filed until it is received in a correct and complete form.

(4) If a hospital knowingly, or has reason to know, files a cost statement containing false information, such action constitutes cause for termination of its agreement with the Division. Hospitals filing false reports may also be referred to prosecution under applicable statutes.

(5) Each Calculation of Reasonable Cost statement submitted to the Division must be signed by the individual who normally signs the hospital's Medicare reports, federal income tax return, and other reports. If the hospital has someone, other than an employee prepare the cost statement, that individual will also sign the statement and indicate his or her status with the hospital.

(6) Notwithstanding subsection (1) of this rule, this subsection becomes effective for dates of service on and after January 1, 2006, but will not be operative as the basis for payments until the Division determines all necessary federal approvals have been obtained. The hospital must file with the Division, an annual Calculation of Reasonable Cost (DMAP 42), covering the latest fiscal period of operation of the hospital:

(b) The hospital must use the same fiscal period for the DMAP 42 as that used for its Medicare report. If it doesn't have an agreement with Medicare, the hospital must use the same fiscal period it uses for filing its federal tax return;

(c) The report must be filed for both inpatient and outpatient services, even if the service is paid under a prospective payment system or fee schedule (e.g., DRG payments, outpatient clinical laboratory, etc.);

(d) In the absence of an agreement with Medicare, the hospital must use the same fiscal period as that used for filing their Federal tax return.

(7) Inpatient rehabilitation facilities are exempt from filing an annual calculation of reasonable Cost (DMAP 42) and not cost settled.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0650
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0105, 461-015-0120 & 461-015-0122
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 39-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Former (2) thru (5) Renumbered to 461-015-0121 thru 461-015-0124
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-1040 Accounting and Record Keeping

(1) All records for a given fiscal period must be kept for three years after the Medicare audit for that period has been finalized.

(2) Each hospital is required to make its financial records available for auditing within the state of Oregon at a location specified by the provider.

(3) All hospital records are subject to inspection and review by Division personnel and Department personnel during the period the records are required to be held.

(4) All expenses must be documented in detail as a part of the record. All capital expenditures requiring approval under the Certificate of Need process, and not having such approval, will be disallowed.

(5) Hospitals without a Medicare agreement must use the Hospital Administrative Services (HAS) system of reporting.

(6) Record keeping and reporting must be based on date of service, not date of payment. Billings for patients determined by the Division to be eligible for Title XIX or Program 5 must be included as accruals, even those billings not yet paid.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert ef. 7-9-90, Renumbered from 461-015-0660
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0121
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 60-1982, f. & cert. ef. 7-1-82; Renumbered from 461-015-0120(2)
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-1060 Fiscal Audits

(1) Year-end fiscal audits will include retrospective examination and verification of claims and the determination of allowable charges and costs of hospital services provided to Division clients.

(2) The principal source document for the fiscal audit of Title XIX/Title XXI and General Assistance patient billings and payments for a given fiscal period is the Division’s data processing printout. This printout includes all transactions for the audit period. Using gross totals from this printout and applying other information from Division records, information received from the hospital, and other sources, the Division will compile detailed schedules of adjustments and revise the gross totals. A revised Calculation of Reasonable Cost Statement (DMAP 42) will be prepared using revised totals and information from the Medicare report.

(3) Cost Settlements: The Division will send the hospital a letter stating the amount of underpayment or overpayment calculated by the Division for the fiscal year examined. The letter will also state the hospital's inpatient/outpatient interim reimbursement rate for the period from the effective date of the change until the next fiscal year's audit is completed. Payment of the cost-settlement amount is due and payable within 30 days from the date of the letter.

(4) The Division, at its discretion, may grant a thirty-day (30) extension for the purpose of reviewing the cost settlement upon a written request by the hospital. If a thirty-day (30) extension is granted, payment of the cost settlement amount is due within sixty (60) days from the date of the letter. If the provider chooses to appeal the decision or rate, a written request for an administrative review, or contested case must be received by the Division within thirty (30) days of the date of the letter notifying the hospital of the settlement amount and interim rate, or within sixty (60) days if the Division has granted a thirty (30) day extension, not withstanding the time limits in OAR 410-120-1580(3) or 410-120-1660(1). Upon receipt of the request, the Division will attempt to resolve any differences informally with the provider before scheduling the administrative review or hearing.

(5) Under extraordinary circumstances, the Division, at its discretion, may negotiate a repayment schedule with a hospital. The hospital may be required to submit additional information to support the hospital's request for a repayment schedule. The hospital will be required to pay interest associated with extended payments granted by the Division.

(6) The revised Calculation of Reasonable Cost, copies of adjustment schedules, and a copy of the printout are available to the hospital upon request. For Type A rural hospitals the Calculation of Reasonable Cost Statement will reflect the difference between payment at 100% of costs and payment for dates-of-services on or after January 1, 2006 under the fee schedule for clinical laboratory services provided by the hospital. An adjustment to the Cost Settlement will be made to reimburse a Type A hospital at 100% of costs for laboratory and radiology services provided to Medical Assistance Program clients during the period the hospital was designated a Type A hospital. Settlements to Type B and Critical Access hospitals will be made within the legislative appropriation.

(7) The adjusted Professional Component Cost-to-Charge ratio(s) will be applied to all corresponding revenue code charges as listed on the Hospital Claim Detail Reports for cost settlements finalized on or after October 1, 1999.

(8) Hospital Based Rural Health Clinics shall be subject to the rules in the Hospital Services for the Oregon Health Plan Guide for Type A and B Hospitals. Hospital Based Rural Health Clinics cost settlements for dates of service from January 1, 2001 shall be finalized to cost.

(9) No interim settlements will be made. No settlements will be made until after receipt and review of the audited Medicare cost report.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 3-1997, f. 1-31-97, cert. ef. 2-1-97
HR 24-1995, f. 12-29-95, cert. ef. 1-1-96
HR 36-1993, f. & cert. ef. 12-1-93
HR 42-1991, f. & cert. ef. 10-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 43-1990, f. & cert. ef. 11-30-90
HR 33-1990(Temp), f. & cert. ef. 10-1-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0670
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0122
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 60-1982, f. & cert. ef. 7-1-82; Renumbered from 461-015-0120(3)
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-1070 Type A and Type B Hospitals

(1) Type A and Type B hospitals must submit the following information to the Division:

(a) The aggregate percent increase in patient charges and the effective date of the increase within 30 days following the end of their fiscal year for increases in the preceding year. Aggregate percent increase in patient charges is defined as the percent increase in patient revenues due to charge increases; and

(b) The amount of payment received by the hospital, from each Division-contracted managed care plan and third-party payers, for inpatient and outpatient hospital services provided to managed care members, within the hospital's fiscal year.

(2) When a hospital is contracted with a Prepaid Health Plan (PHP), within thirty (30) days of the Division’s request the hospital will supply the Division the following information:

(a) The name of the contracting PHP; and

(b) The dates for which the contract will be effective; and

(3) The hospital and PHP must coordinate payment information to verify and return the PHP payment data file sent by the Division within ninety (90) days from date the data file is received by the hospital.

(4) Failure to supply the requested information within timelines stated may result in a discretionary sanction or fine (see OAR 410-120-1440). No sanction or fine will be imposed if the Division determines, at its sole discretion, that the hospital was unable to coordinate payment information with the PHP through no fault of the hospital’s own.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 31-2005, f. 6-20-05, cert. ef. 7-1-05
OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01

Or. Admin. R. 410-125-1080 Documentation

(1) Federal regulations require Medicaid providers to maintain records that fully support the extent of services for which payment has been requested, and that such records be furnished to the Division upon request (42 CFR 431.107).

(2) When requested by the Division or its medical review contractor, hospitals must submit sufficient medical documentation to verify the emergency nature, medical necessity, quality and appropriateness of treatment, and appropriateness of the length of stay for inpatient and outpatient hospital services. The Division may request sufficient information to evaluate the accuracy and appropriateness of ICD-10-CM Coding for the claim. In addition, the Division may request an itemized billing for all services provided. The Division will specify in its request what documentation is required.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0680
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0040
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 60-1982, f. & ef. 7-1-82
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-2000 Access to Records

(1) Providers must furnish requested medical and financial documentation within 30 calendar days from the date of request. Failure to comply within 30 calendar days shall result in recovery of payment(s) made by the Division for services being reviewed.

(2) The Division conducts post payment review of admissions and claim records. The Division may request records from a hospital or may request access to records while at the hospital.

(3) The hospital has 30 days to provide the Division with copies of records. In some cases, there may be a more urgent need to review records.

(4) The Medical Payment Recovery Unit (MPRU) conducts recovery activities for the Division involving third party liability resources. MPRU may request records from the hospital. This unit has the same right to medical and financial information as the Division.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 11-2004, f. 3-11-04, cert. ef. 4-1-04
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0690
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0040
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 60-1982, f. & ef. 7-1-82
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-2020 Post Payment Review

(1) All services provided by a hospital in the inpatient or outpatient setting are subject to post-payment review by the Division. Both emergency and non-emergency services may be reviewed. Claims for services may be reviewed to determine:

(a) The medical necessity of the admission or outpatient services provided;

(b) The appropriateness of the length of stay;

(d) The accuracy of the ICD-10 coding and DRG assignment;

(e) The appropriateness of the setting selected for service delivery;

(f) The quality of care of the services provided;

(g) The nature of any service coded as emergent;

(h) The accuracy of the billing;

(i) The care furnished is appropriately documented.

(2) If the Division determines that a hospital service was not within Division coverage parameters, the hospital and attending physician shall be notified in writing and will have twenty days to provide additional written documentation to support the medical necessity of the admission and/or procedure(s).

(3) If the recommendation for denial is upheld by the Division, the hospital and/or practitioner may request a reconsideration of the denial within 30 days of the receipt of the denial.

(4) If the reconsidered decision is to uphold the denial, payment to all providers of service shall be recovered.

(5) The hospital and/or practitioner may appeal any final decision through the Division administrative appeals process.

(6) No payment shall be made by the Division for inpatient services if the Division or Medicare has determined the service is not medically necessary and/or appropriate.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0700
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0090
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 46-1987, f. & ef. 10-1-87
AFS 38-1986, f. 4-29-86, ef. 6-1-86
AFS 1-1984, f. & ef. 1-9-84
AFS 14-1980, f. 3-27-80, ef. 4-1-80

Or. Admin. R. 410-125-2030 Recovery of Payments

(1) Payments made by the Division of Medical Assistance Programs (Division) shall be recovered for:

(a) Services identified by the provider as emergent or urgent, but determined on retrospective review not to have been emergent or urgent. Payment shall also be recovered from the admitting and/or performing physician;

(b) Services determined by the Division that the readmission to the same hospital was the result of a premature discharge;

(d) Services provided at an inappropriate level of care, which includes the setting selected for service delivery;

(e) The Division non-covered services;

(f) Services, which were covered by a third party payer or other resources; or

(g) Services denied by a third party payer as not medically necessary.

(2) Payment to a physician and other providers of service for inpatient non-urgent or non-emergent services requiring prior authorization is subject to recovery by the Division if recovery is made from the hospital.

(3) If review by the Division results in a denial, the hospital may appeal any final decision through the Division Administrative Appeals process. See Administrative Hearings (chapter 410, division 120).

(4) As part of the Utilization Review Program, the Division shall develop and maintain a data system profiling the patterns of practice of institutions and practitioners. As a result of these profiles, the Division may initiate focused reviews. Any practitioner or hospital subject to a focused review shall be notified in advance of the review.

(5) All providers having a pattern of inappropriate utilization or inappropriate quality of care according to the current standards of the medical community and/or abuse of the Division rules or procedures shall be subject to corrective action. Actions taken shall be those determined appropriate by the Division, or sanctions established under the Oregon Revised Statues (ORS) or Oregon administrative rule and/or referral to a State or Federal authority, licensing body or regulatory agency for appropriate action.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 42-1991, f. & cert. ef. 10-1-91

Or. Admin. R. 410-125-2040 Provider Appeals — Administrative Review

(1) A provider may request an administrative review regarding the decision(s) by the Division that affect the services they provide or have provided. See General Rules (chapter 410 division 120).

(2) A requests for an administrative review must be submitted in writing to the Medicaid Administrator, 500 Summer Street NE, E49, Salem, OR 97301-1079.

(3) The request must be received within 30 days of the date of notification of the payment decision or notification of change in reimbursement.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0710
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Or. Admin. R. 410-125-2060 Provider Appeals — Hearing Request

If the hospital disagrees with the Division calculation of reasonable costs for outpatient services or inpatient services, the outpatient interim rate, Diagnosis-Related Groups based prospective payment for inpatient services, the calculation of the hospital's unit value, or any other hospital reimbursement methodologies or payments, a written request for an appeal may be made to the Division in accordance with the General rules (chapter 410 division 120). A hearing request must be received not later than 30 days following the date of the notice of action. At the time of appeal, the hospital must submit any data the hospital wants the Division to consider in support of the appeal. The appeal will be conducted as described in General rules.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0720
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0123
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(4)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80

Or. Admin. R. 410-125-2080 Administrative Errors

(1) If a hospital has been given incorrect information by the Division of Medical Assistance Programs, or Children, Adults, and Families Programs, or Aging and People with Disabilities/staff, and services were provided on the basis of this information, and payment has been denied as a result, the hospital may submit a request for payment as an administrative error.

(2) Include the following:

(a) An explanation of the problem;

(b) Any documents supporting the request for payment;

(d) A copy of the original claim.

(3) Send the request: Division of Medical Assistance Programs, Provider Inquiry, Administrative Errors, 500 Summer Street NE, E-44, Salem, OR 97301-1077.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
HR 42-1991, f. & cert. ef. 10-1-91
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0730
AFS 72-1989, f. & cert. ef. 12-1-89
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89

Division 127 HOME HEALTH CARE SERVICES

Or. Admin. R. 410-127-0020 Definitions

(1) “Acquisition Cost” means the net invoice price of the item, supply, or equipment plus shipping or postage for the item.

(2) “Assessment” means procedures by which a client’s health strengths, weaknesses, problems, and needs are identified.

(3) “Custodial Care” means provision of services and supplies that can safely be provided by non-medical or unlicensed personnel.

(4) “Division ” means the Health Systems Division within the Oregon Health Authority (Authority). The Division is responsible for coordinating medical assistance programs within the State of Oregon including the Oregon Health Plan (OHP), the State Children’s Health Insurance Program (SCHIP-Title XXI), and several other programs.

(5) “Electronic Visit Verification (EVV)” means a technological solution used to electronically verify home health providers delivered or rendered home health services. EVV data to be collected in real time for each visit includes:

(a) Provider number of agency;

(b) Individual name of provider rendering the service;

(d) Service date;

(e) Start and end time (to the minute);

(f) Location (geo location) of service delivery;

(g) Type of service performed.

(6) “Evaluation” means a systematic objective assessment of the client for the purpose of forming a plan of treatment and a judgment of the effectiveness of care and measurement of treatment progress. The evaluation of direct care and effectiveness of care plans and interventions is an ongoing activity.

(7) “Home” as it relates to home health services, means a place of temporary or permanent residence used as an individual’s home including assisted living facilities, residential care facilities and foster homes. This does not include a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, any setting that exists primarily for the purpose of providing medical/nursing care, or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

(8) “Home Health Agency” means a public or private agency or organization that meets requirements for participation in Medicare, including the capitalization requirements under 42 CFR 489.28, and is licensed by the Authority as a home health agency in Oregon. Home health agency does not include:

(a) Any visiting nurse service or home health service conducted by and for those who rely upon spiritual means through prayer alone for healing in accordance with tenets and practices of a recognized church or religious denomination;

(b) Health services offered by county health departments that are not formally designated and funded as home health agencies within the individual departments;

(9) “Home Health Aide” means an individual who meets all requirements for home health aide as defined in the Medicare Conditions of Participation at 42 CFR 484.80 and who is certified as a nursing assistant by the Oregon State Board of Nursing in accordance with OAR chapter 851, division 062.

(10) “Home Health Aide Services” means services provided by a home health aide on a part-time or intermittent basis, under the direction and supervision of a registered nurse or licensed therapist familiar with the client, the client’s plan of care, and the written care instructions. The focus of care shall be to provide personal care services or other services under the home health services plan of care needed to maintain the client’s health or to facilitate treatment of the client’s illness or injury. These services must not duplicate other Medicaid-paid personal care services.

(11) “Home Health Services” means the following items and services furnished to a client who is under the care of a physician, by a home health agency, under a plan established and periodically reviewed by a physician, on a visiting basis:

(a) Part-time or intermittent nursing care provided by or under the supervision of a registered nurse;

(b) Physical, occupational, or speech-language pathology services;

(c) Part-time or intermittent home health aide services provided by a home health aide who has successfully completed the required training and certification; and

(d) Medical supplies and durable medical equipment.

(12) “Medicaid Home Health Provider” means a home health agency licensed by Health Services, Health Care Licensure and Certification certified for Medicare and enrolled with the Division as a Medicaid provider.

(13) “Medical Supplies” means supplies prescribed by a physician as a necessary part of the plan of care being provided by the home health agency.

(14) “Outcome and Assessment Information Set (OASIS)” means a client specific comprehensive assessment that identifies the client's need for home health services that meet the client's medical, nursing, rehabilitative, social, and discharge planning needs.

(15) “Occupational Therapy Services” means services provided by a registered occupational therapist or certified occupational therapy assistant supervised by a registered occupational therapist, due to the complexity of the service and client's condition. The focus of these services shall be curative, rehabilitative, or preventive and must be considered specific and effective treatments for a client's condition under accepted standards of medical practice. Teaching the client, family, and caregiver task-oriented therapeutic activities designed to restore function and independence in the activities of daily living is included in this skilled service. Occupational Therapy Licensing Board ORS 675.210-675.340 and the Uniform Terminology for Occupational Therapy established by the American Occupational Therapy Association, Inc. govern the practice of occupational therapy.

(16) “Physical Therapy Services” means services provided by a licensed physical therapist or licensed physical therapy assistant under the supervision of a licensed physical therapist, due to the inherent complexity of the service and the client's condition. The focus of these services shall be curative, rehabilitative, or preventive and must be considered specific and effective treatments for a patient's condition under accepted standards of medical practice. Teaching the client, family, and caregiver the necessary techniques, exercises, or precautions for treatment and prevention of illness or injury is included in this skilled service. Physical Therapy Licensing Board ORS 688.010 to 688.235 and Standards for Physical Therapy as well as the Standards of Ethical Conduct for the Physical Therapy Assistant established by the American Physical Therapy Association govern the practice of physical therapy. Physical therapy shall not include radiology or electrosurgery.

(17) “Plan of Care” means written instructions describing how care is to be provided. The plan is initiated by the admitting registered nurse, physical therapist, occupational therapist, or speech therapist and certified by the prescribing physician. The plan of care must include the client’s condition, rationale for the care plan including justification for the skill level of care, and the summary of care for additional certification periods. This includes but is not limited to:

(a) All pertinent diagnoses;

(b) Mental, psychosocial, and cognitive status;

(d) Specific therapy services;

(e) Frequency and duration of visits to be made;

(f) Supplies and equipment needed;

(g) Prognosis;

(h) Rehabilitation potential;

(i) Functional limitations;

(j) Activities permitted;

(k) Nutritional requirements;

(L) All medications and treatments;

(m) Safety measures to protect against injury;

(n) Discharge plans including patient and caregiver education and training to facilitate timely discharge;

(o) Patient-specific measurable outcomes/goals;

(p) If home health services are initiated following a hospital discharge, an assessment of client’s level of risk for hospital emergency department visits or hospital readmission;

(q) Additional interventions/orders the home health agency or physician chooses to include.

(18) “Practitioner” means an individual licensed pursuant to federal and state law to engage in the provision of health care services within the scope of the practitioner’s license and certification.

(19) “Responsible Unit” means the agency responsible for approving or denying payment authorization.

(20) “Skilled Nursing Services” means the client care services pertaining to the curative, restorative, or preventive aspects of nursing performed by a registered nurse or under the supervision of a registered nurse, pursuant to the plan of care established by the prescribing physician in consultation with the home health agency staff. Skilled nursing emphasizes a high level of nursing direction, observation, and skill. The focus of these services shall be the use of the nursing process to diagnose and treat human responses to actual or potential health care problems, health teaching, and health counseling. Skilled nursing services include the provision of direct client care and the teaching, delegation, and supervision of others who provide tasks of nursing care to clients, as well as phlebotomy services. Such services shall comply with the Nurse Practice Act and administrative rules of the Oregon State Board of Nursing and Health Division, chapter 410 division 127, Home Health Agencies.

(21) “Speech-Language Pathology Services” means services provided by a licensed speech-language pathologist due to the inherent complexity of the service and the patient's condition. The focus of these services shall be curative, rehabilitative, or preventive and must be considered specific and effective treatment for a patient's condition under accepted standards of medical practice. Teaching the client, family, and caregiver task-oriented therapeutic activities designed to restore function and compensatory techniques to improve the level of functional communication ability is included in this skilled service. Speech-Language Pathology and Audiologist Licensing Board ORS 681.205 to 681.991 and the Standards of Ethics established by the American Speech and Hearing Association govern the practice of speech-language pathology.

(22) “Title XVIII (Medicare)” means Title XVIII of the Social Security Act.

(23) “Title XIX (Medicaid)” means Title XIX of the Social Security Act.

[Note: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 91-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 4-2020, amend filed 02/24/2020, effective 02/25/2020
DMAP 32-2019, temporary amend filed 08/13/2019, effective 08/19/2019 through 02/14/2020
DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018
DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18
DMAP 29-2013, f. & cert. ef. 6-27-13
DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 36-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 24-1998, f. & cert. ef. 7-15-98
OMAP 4-1998(Temp), f. & cert. ef. 2-5-98 thru 7-15-98
HR 15-1995, f. & cert. ef. 8-1-95
HR 14-1992, f. & cert. ef. 6-1-92
HR 12-1991, f. & cert. ef. 3-1-91
HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0001
SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90
SSD 4-1983, f. 5-4-83, ef. 5-5-83

Or. Admin. R. 410-127-0040 Coverage

(1) Medically appropriate home health services may be covered on a visiting basis to eligible clients as ordered by a physician and part of a written plan of care. Coverage of home health services is not contingent on the client needing nursing, nursing facility or therapy services.

(2) Home health services may be provided in the client’s home or any setting in which normal life activities take place other than a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, any setting that exists primarily for the purpose of providing medical/nursing care, or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

(3) Home health services require a face-to-face encounter as described in OAR 410-127-0045 consistent with federal Medicaid regulations at 42 CFR 440.70.

(4) Home health services must be prescribed by a physician, and the signed order must be on file at the home health agency. The prescription must include the ICD-10-CM diagnosis code indicating the reason the home health services are requested. The orders on the plan of care must specify the type of services to be provided to the client with respect to the professional who will provide them, the nature of the individual services, specific frequency, and specific duration. The orders must clearly indicate how many times per day, each week or each month the services are to be provided. The plan of care must include the client’s condition, the rationale for the care plan including justification for the required skill level of care, and the summary of care for additional certification periods.

(5) The plan of care must be reviewed and signed by the physician who established the plan of care at least every 60 days to continue services.

(6) The following services or items are covered, if diagnoses are on the portion of the prioritized list above the line funded by the legislature:

(a) Skilled nursing services;

(b) Skilled nursing evaluation (includes Outcome and Assessment Information Set (OASIS) assessment);

(d) Occupational therapy services;

(e) Occupational therapy evaluation, which may include OASIS assessment;

(f) Physical therapy services;

(g) Physical therapy evaluation, which may include OASIS assessment;

(h) Speech-language pathology services, which may include OASIS assessment;

(i) Speech-language pathology evaluation, which may include OASIS assessment;

(j) Medical and surgical supplies.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 4-2020, amend filed 02/24/2020, effective 02/25/2020
DMAP 32-2019, temporary amend filed 08/13/2019, effective 08/19/2019 through 02/14/2020
DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018
DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 29-2013, f. & cert. ef. 6-27-13
OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00
HR 15-1995, f. & cert. ef. 8-1-95
HR 14-1992, f. & cert. ef. 6-1-92
HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0000
SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90
SSD 4-1983, f. 5-4-83, ef. 5-5-83
Renumbered from 461-019-0400, AFS 69-1981, f. 9-30-81, ef. 10-1-81
AFS 8-1979, f. 3-30-79, ef. 4-1-79
PWC 798, f. & ef. 6-1-76
PWC 682, f. 7-19-74, ef. 8-11-74

Or. Admin. R. 410-127-0045 Face-to-Face Encounter Requirements for Home Health Services

(1) The Division requires that for the initial ordering of home health services, an in-person face-to-face encounter that is related to the primary reason the client requires the home health services must occur within not more than 90 days before or 30 days after the start of services.

(2) The face-to-face encounter shall be conducted by:

(a) The certifying physician (MD or DO); or

(b) An authorized non-physician practitioner (NPP); or

(c) An attending or post-acute physician for clients admitted to home health immediately after an acute or post-acute stay.

(3) Authorized NPP’s for home health services are nurse practitioners, a clinical nurse specialist working in collaboration with the physician, or a physician associate under the supervision of a physician.

(4) If an authorized NPP performs the face-to-face encounter, they shall communicate the clinical findings to the certifying physician. Those clinical findings must be incorporated into a written or electronic document included in the client’s medical record.

(5) The certifying physician shall document that the client was evaluated or treated for a condition that supports the need for the home health services ordered within no more than 90 days before or 30 days after the start of services. The certifying physician shall also document the name of the practitioner who conducted the encounter and the date of the encounter.

(6) The documentation of the face-to-face encounter must be a separate and distinct section of or an addendum to the certification and must be clearly titled, dated, and signed by the certifying physician.

(7) A face-to-face encounter must occur for certification any time a new start of care assessment is completed to initiate care for the home health services.

(8) If a dually eligible client begins home health under Medicare and transitions to Medicaid, the Medicare face-to-face encounter documentation shall meet the Medicaid face-to-face requirement.

(9) The home health agency shall maintain documentation of the qualifying face-to-face encounter and provide this documentation to the Division with the prior authorization request for services.

History

Statutory/Other Authority: 411.404 & 414.065
Statutes/Other Implemented: 414.065
DMAP 10-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 2-2018, adopt filed 01/10/2018, effective 01/10/2018
DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18

Or. Admin. R. 410-127-0046 Electronic Visit Verification (EVV)

(1) The Home Health Care Agencies must comply with Section 12006(a) of the 21st Century Cures Act by electronically verifying Home Health services. Oregon Medicaid has selected the Provider Choice Model for EVV. Home Health Care agencies must provide a method to capture EVV information that meets the requirements of the 21st Century Cures Act.

(2) The submission of EVV data to the Authority by the Home Health Care agency provider is certification that the foregoing information is true, accurate, and complete.

(a) Provider specific EVV solutions that do not capture the start time and end time to the minute are not EVV compliant;

(b) Provider specific EVV solutions that do not capture geo location coordinates at the start time and again at the end time of service provided are not EVV compliant;

(c) Provider alteration of one or more data points in a provider specific EVV solution record, prior to sending that record to the Department or Authority for payment is prohibited;

(d) Home health services that are not EVV compliant are not eligible for payment and payments may be denied or recovered from the Home Health Care agency provider;

(e) The Authority does not grant exceptions to Home Health Care agency providers for provider specific EVV solutions. A provider who is enrolled by the Authority shall comply with department guidance to determine whether a limited exception for an individual or a rendering provider employed by the provider may be permitted by the Authority. See administrative rule chapter 411;

(f) The requirement to use EVV does not apply to individuals enrolled and living in a residential service setting, including 24-hour group homes, foster care homes, supported living, or receiving On the Job Attendant Care, or Day Support Activities. EVV does not include any employment or community transportation services.

(3) The following data elements are required to be reported to Oregon Health Authority monthly:

(a) Provider number of Agency;

(b) Individual name of provider rendering the service;

(d) Service Date;

(e) Start and end time (to the minute);

(f) Location (geo location) of service delivery;

(g) Type of service performed;

(4) Home Health Agencies must use the reporting template and submit reports each month to HH.EVVData@oha.oregon.gov.

(5) Payment by the Authority or Department does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit a claim before or after the payment. Payment may be denied or subject to recovery if the review or audit determines the care, service or item was not provided in accordance with this EVV rule or does not meet the criteria for quality or medical appropriateness of the care, service or item or payment.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 91-2023, adopt filed 12/21/2023, effective 01/01/2024

Or. Admin. R. 410-127-0060 Reimbursement and Limitations

(1) The Division reimburses home health services on a fee schedule by type of visit (see home health rates on the Authority’s website at: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Home-Health.aspx).

(2) The Division recalculates its home health services rates every other year. The Division shall reimburse home health services at a level of 74 percent of Medicare costs reported on the audited, most recently accepted or submitted Medicare Cost Reports prior to the rebase date and pending approval from the Centers for Medicare and Medicaid Services (CMS), and, if indicated, legislative funding authority.

(3) The Division shall request the Medicare Cost Reports from home health agencies with a due date and shall recalculate potential rates based on the Medicare Cost Reports received by the requested due date. The home health agency shall submit requested cost reports by the date requested.

(4) The Division reimburses only for services that are medically appropriate.

(5) Limitations:

(a) Limits of covered services:

(A) Skilled nursing visits are limited to two visits per day with payment authorization;

(B) All therapy services are limited to one visit or evaluation per day for physical therapy, occupational therapy, or speech-language pathology services. Therapy visits require payment authorization;

(C) Home health aide services are limited to those ordered by a physician, included in the plan of care, permitted to be performed under state law, consistent with home health aide training, and under the direction of a registered nurse or licensed therapist familiar with the client and the client’s plan of care. These services must not duplicate other Medicaid-paid personal care services.

(D) The Division shall authorize home health visits for clients with uterine monitoring only for medical problems that could adversely affect the pregnancy and are not related to the uterine monitoring;

(E) Medical supplies must be billed at acquisition cost, and the total of all medical supply revenue codes may not exceed $50 per day. Only supplies that are used during the visit or the specified additional supplies used for current client/caregiver teaching or training purposes as medically appropriate are billable. Client visit notes must include documentation of supplies used during the visit or supplies provided according to the current plan of care;

(F) Durable medical equipment must be obtained by the client by prescription through a durable medical equipment provider.

(b) Services not covered:

(A) Service not medically appropriate;

(B) A service for a diagnosis that does not appear on a line of the Prioritized List of Health Services that has been funded by the Oregon Legislature (OAR 410-141-0520);

(D) Registered dietician counseling or instruction;

(E) Drug and biological;

(F) Fetal non-stress testing;

(G) Respiratory therapist service;

(H) Flu shot;

(I) Psychiatric nursing service.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 4-2020, amend filed 02/24/2020, effective 02/25/2020
DMAP 32-2019, temporary amend filed 08/13/2019, effective 08/19/2019 through 02/14/2020
DMAP 46-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018
DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18
DMAP 29-2013, f. & cert. ef. 6-27-13
DMAP 39-2011, f. 12-15-11, cert. ef. 1-1-12
DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12
DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 16-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 77-2003, f. & cert. ef. 10.1.03
OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00
HR 15-1995, f. & cert. ef. 8-1-95
HR 14-1992, f. & cert. ef. 6-1-92
HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0010
SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90
SSD 4-1983, f. 5-4-83, cert. ef. 5-5-83
AFS 69-1981, f. 9-30-81, cert. ef. 10-1-81, Renumbered from 461-019-0420
PWC 854(Temp), f. 9-30-77, cert. ef. 10-1-77 thru 1-28-78
PWC 798, f. & cert. ef. 6-1-76
PWC 682, f. 7-19-74, cert. ef. 8-11-74

Or. Admin. R. 410-127-0065 Signature Requirements

(1) Physicians shall sign for services they order. This signature shall be handwritten or electronic, and it must be in the client's medical record.

(2) The ordering physician shall ensure the authenticity of the signature.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018
DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18
DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 38-2006, f. 12-15-06, cert. ef. 1-1-07

Or. Admin. R. 410-127-0080 Prior Authorization

(1) Home health providers must obtain prior authorization (PA) for services as specified in rule.

(2) Providers must request PA as follows (see the Home Health Supplemental Information booklet for contact information) and include the documentation requirements from the supplemental (e.g., face-to-face encounter, plan of care, primary diagnosis, initial assessment, evaluation, etc.):

(a) For clients enrolled in a Coordinated Care Organization (CCO) or a Prepaid Health Plan (PHP), from the CCO or the PHP;

(b) For all other clients, from the Division.

(3) For services requiring authorization, providers must contact the responsible unit for authorization within five working days following initiation or continuation of services. The FAX or postmark date on the request shall be honored as the request date. The provider shall obtain payment authorization. Authorization shall be given based on medical appropriateness and appropriate level of care, cost, and effectiveness as supported by submitted documentation. The plan of care submitted must include the client’s condition, the rationale for the care plan including justification for the required skill level of care, and the summary of care for additional certification periods.

(4) Payment authorization does not guarantee reimbursement (e.g., eligibility changes, incorrect identification number, provider contract ends).

(5) For rules related to authorization of payment including retroactive eligibility, see General Rules OAR 410-120-1320.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018
DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18
DMAP 29-2013, f. & cert. ef. 6-27-13
DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 91-2003, f. 12-30-03, cert. ef. 1-1-04
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 15-1999, f. & cert. ef. 4-1-99
HR 15-1995, f. & cert. ef. 8-1-95
HR 2-1993, f. 2-19-93, cert. ef. 2-20-93
HR 30-1992(Temp), f. & cert. ef. 9-25-92
HR 12-1991, f. & cert. ef. 3-1-91
HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0005
SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90
SSD 6-1986, f. & ef. 4-24-86
SSD 4-1983, f. 5-4-83, ef. 5-5-83
Renumbered from 461-019-0410, AFS 69-1981, f. 9-30-81, ef. 10-1-81
AFS 8-1979, f. 3-30-79, ef. 4-1-79
PWC 798, f. & ef. 6-1-76
PWC 682, f. 7-19-74, ef. 8-11-74

Or. Admin. R. 410-127-0200 Home Health Revenue Center Codes

Payment authorization is required for those services indicated by the Code PA. Following are the procedure codes to be used for billing:

(1) Medical/surgical supplies and devices:

(a) 270 -- General classification;

(b) 271 – Non-sterile supply;

(2) Physical Therapy:

(a) 421 -- Visit charge -- PA;

(b) 424 -- Evaluation (includes OASIS assessment) or re-evaluation.

(3) Occupational Therapy:

(a) 431 -- Visit charge -- PA;

(b) 434 -- Evaluation or re-evaluation.

(4) Speech-language pathology:

(a) 441 -- Visit charge -- PA;

(b) 444 -- Evaluation (includes OASIS assessment) or re-evaluation.

(5) Skilled nursing:

(a) 551 -- Visit charge -- PA;

(b) 559 -- Other skilled nursing -- evaluation (includes OASIS assessment).

(6) Home health aide -- 571 -- Visit charge -- PA.

(7) Total charge -- 001 -- Total Charge.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 4-2020, amend filed 02/24/2020, effective 02/25/2020
DMAP 32-2019, temporary amend filed 08/13/2019, effective 08/19/2019 through 02/14/2020
DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018
DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18
OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00
HR 15-1995, f. & cert. ef. 8-1-95
HR 14-1992, f. & cert. ef. 6-1-92
HR 12-1991, f. & cert. ef. 3-1-91
HR 28-1990, f. 8-31-90, cert. ef. 9-1-90

Division 129 SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES

Or. Admin. R. 410-129-0020 Therapy Plan of Care, Goals, Outcomes, and Record Requirements

(1) Therapy shall be based on a prescribing practitioner’s written order and therapy treatment plan with goals and objectives developed from an evaluation or re-evaluation. The limits, authorization, and plan of treatment criteria apply to both rehabilitative and habilitative therapy. The definition for both is the following:

(a) “Rehabilitative Services” means health care services that help an individual re-establish, restore, or improve skills and functioning for daily living that have been lost or impaired due to illness, injury, or disability;

(b) “Habilitative Services” means health care services that help an individual keep, learn, or improve skills and functioning for daily living, designed to establish skills that have not yet been acquired at an age-appropriate level. Examples include therapy for a child who is not walking or talking at the expected age.

(2) A total of thirty (30) visits per year of rehabilitative therapy and a total of thirty (30) visits per year of habilitative therapy (speech therapy) are included when medically appropriate. Additional visits, not to exceed thirty (30) visits per year of rehabilitative therapy and thirty (30) visits per year of habilitative therapy, may be authorized in cases of a new acute injury, surgery, or other significant change in functional status. Children under age 21 may have additional visits authorized beyond these limits if medically necessary and medically appropriate, pursuant to 42 CFR § 441 Subpart B.

(3) The therapist shall teach the therapy regimen to individuals, including the client, family members, foster parents, and caregivers who can assist in the achievement of the goals and objectives. The client must be present when the therapy is appropriately demonstrated at the time of teaching to assure that the therapy regimen is performed safely and correctly. The Division may not authorize extra treatments for teaching.

(4) All Speech-Language Pathology (SLP) treatment services require a therapy plan of care that is required for claims subject to prepayment review (PPR) or requiring Prior Authorization (PA) for payment.

(5) The Division shall provide authorization for the level of care or type of service that meets the client’s medical need consistent with the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List) and the American Hippotherapy Association’s (AHA) position on coding and billing for equine related modalities.

(6) These rules do not limit or affect any obligations of a school district or education entity eligible for reimbursement for covered, health-related services provided in support of a child with a disability education program required by state and federal law. School-sponsored services are supplemental to other health plan therapy services and are not considered duplicative. See OAR chapter 410, division 133 SBHS rules for services provided by public education providers and OAR 410-141-3565 (Managed Care Entity (MCE) Billing).

(7) The SLP therapy plan must adhere to the licensing board requirements of care and shall include:

(a) Client’s name and ICD diagnosis code;

(b) The type, amount, frequency, and duration of the proposed rehabilitative or habilitative therapy;

(d) Dated signature of the therapist or the prescribing practitioner establishing the therapy plan of care; and

(e) Evidence of certification of the therapy plan of care by the prescribing practitioner.

(8) SLP therapy records must be compliant with applicable record and documentation requirements (see Oregon Administrative Rules in chapter 335, division 010).

(9) Documentation of clinical activities may be supplemented using flowsheets or checklists; however, these may not substitute for or replace detailed documentation of assessments and interventions.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 56-2017, amend filed 12/26/2017, effective 01/01/2018
DMAP 19-2017, f. & cert. ef. 6-9-17
DMAP 70-2016(Temp), f. 12-5-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 22-2014, f. & cert. ef. 4-2-14
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 36-1994, f. 12-30-94, cert. ef. 1-1-95
HR 27-1993, f. & cert. ef. 10-1-93
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91

Or. Admin. R. 410-129-0060 Prescription Required

(1) The prescription is the written order by the prescribing practitioner pursuant to state law governing SLP, audiology, and hearing aid services. Prescription shall specify the ICD diagnosis code for all SLP, audiology, and hearing aid services that require payment/prior authorization.

(2) The provision of speech therapy services shall be supported by a written order and a therapy treatment plan signed by the prescribing practitioner. A practitioner means an individual licensed pursuant to state law to engage in the provision of health care services within the scope of the practitioner’s license or certification.

(3) A written order:

(a) Is required for the initial evaluation;

(b) For therapy, shall specify the ICD diagnosis code, service, amount, and duration required.

(4) Written orders shall be submitted with claims that are subject to PPR or that require PA request, and a copy shall be on file in the provider’s therapy record. The written order and the treatment plan shall be reviewed and signed by the prescribing practitioner every six months.

(5) Authorization of payment to an audiologist or hearing aid dealer for a hearing aid will be considered only after examination for ear pathology and written prescription for a hearing aid by an ear, nose, and throat specialist (ENT) or general practitioner who has training to examine the ear and performs within the scope of his practice, i.e., primary care physician (not appropriate for an orthopedic specialist, chiropractor, gynecologist, etc.).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 56-2017, amend filed 12/26/2017, effective 01/01/2018
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 6-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 36-1994, f. 12-30-94, cert. ef. 1-1-95
HR 27-1993, f. & cert. ef. 10-1-93
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91, Renumbered from 461-021-0301
AFS 67-1985, f. 11-19-85, ef. 12-1-85

Or. Admin. R. 410-129-0065 Licensing Requirements

(1) The Division enrolls only the following types of providers as performing providers under the Speech-Language Pathology, Audiology and Hearing Aid Services program:

(a) An individual licensed by the relevant state licensing authority to practice speech-language pathology (SLP);

(b) An individual licensed by the relevant state licensing authority to practice audiology; and

(c) An individual licensed by the relevant state licensing authority for “dealing in hearing aids” as defined in Oregon Revised Statute 694.015.

(2) The Oregon Board of Examiners for SLP and Audiology licenses and the Division recognizes services provided by:

(a) Conditional Speech-Language Pathologists; and

(b) SLP Assistants.

(3) Services of graduate SLP students, furnished under a Conditional SLP License:

(a) Shall be provided in compliance with supervision requirements of the state licensing board and the American Speech-Language-Hearing Association;

(b) Shall be compliant with applicable record and documentation requirements (see also Oregon Administrative Rules in chapter 335, division 010); and

(4) The Division shall not reimburse for services of a licensed speech-language pathologist while the pathologist is teaching or supervising students in SLP.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 22-2014, f. & cert. ef. 4-2-14
OMAP 59-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 27-1993, f. & cert. ef. 10-1-93

Or. Admin. R. 410-129-0070 Limitations

(1) Speech Language Pathology (SLP) services:

(a) Shall be provided by a practitioner as described in OAR 410-129-0065;

(b) Requirements for rehabilitative and habilitative therapy treatment:

(A) Require Prior Authorization (PA) when it exceeds one hour per day each for a group or individual;

(B) Shall be either group or individual and may not be combined in the authorization period; and

(A) Two SLP evaluations in a 12-month period;

(B) Two evaluations for dysphagia in a 12-month period;

(D) One evaluation for speech-generating/augmentative communication system or device (SGD) shall be reimbursed per recipient in a 12-month period;

(E) One evaluation for voice prosthesis or artificial larynx shall be reimbursed in a 12-month period;

(F) Purchase, repair, or modification of electrolarynx;

(G) Supplies for speech therapy shall be reimbursed up to two times in a 12-month period, not to exceed five dollars each.

(d) The purchase, rental, repair, or modification of a SGD requires PA. Rental of a SGD is limited to one month. All rental fees shall be applied to the purchase price.

(2) Audiology and hearing aid services:

(a) All hearing services shall be performed by a licensed physician, audiologist, or hearing aid specialist;

(b) Binaural hearing aids shall be reimbursed no more frequently than every five (5) years for individuals age 21 and older who meet the following criteria and medical necessity: Loss of 35 decibel (dB) hearing level or greater in two or more of the following frequencies: 1000, 2000, 3000, and 4000 Hertz (Hz);

(c) Binaural hearing aids shall be reimbursed no more frequently than every three (3) years for children, birth through age 20, who meet the following criteria:

(A) Pure tone average of 25dB for the frequencies of 500Hz, 1000Hz, and 2000Hz; or

(B) High frequency average of 35dB for the frequencies of 3000Hz, 4000Hz, and 6000Hz.

(d) An assistive listening device may be authorized for individuals aged 21 or over who are unable to wear or who cannot benefit from a hearing aid. An assistive listening device is defined as a simple amplification device designed to help the individual hear in a listening situation. It is restricted to a hand-held amplifier and headphones;

(e) The following services do not require PA:

(A) One basic audiologic assessment in a 12-month period;

(B) One basic comprehensive audiometry (audiologic evaluation) in a 12-month period;

(D) One pure tone audiometry (threshold) test; air and bone in a 12-month period;

(E) One electroacoustic evaluation for hearing aid; monaural in a 12-month period;

(F) One electroacoustic evaluation for hearing aid; binaural in a 12-month period;

(G) Hearing aid batteries – maximum of 60 individual batteries in a 12-month period. Clients shall meet the criteria for a hearing aid.

(f) The following services require PA:

(A) Hearing aids;

(B) Repair of hearing aids, including ear mold replacement;

(D) Assistive listening devices;

(E) Cochlear implant batteries:

(F) Bone anchored hearing aid (BAHA) replacement components.

(g) The following services require PA and must meet medical necessity and medical appropriateness under Early and Periodic Screening, Diagnostic and Treatment (EPSDT):

(A) FM systems;

(B) Vibro-tactile aids;

(h) Services not covered:

(A) Adjustment of hearing aids are included in the fitting and dispensing fee and is not reimbursable separately;

(B) Aural rehabilitation therapy is included in the fitting and dispensing fee and is not reimbursable separately;

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & ORS 414.025
DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 46-2021, amend filed 10/22/2021, effective 10/22/2021
DMAP 17-2021, temporary amend filed 05/05/2021, effective 05/05/2021 through 10/31/2021
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 56-2017, amend filed 12/26/2017, effective 01/01/2018
DMAP 19-2017, f. & cert. ef. 6-9-17
DMAP 70-2016(Temp), f. 12-5-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 22-2014, f. & cert. ef. 4-2-14
DMAP 17-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 14-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 39-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 36-1994, f. 12-30-94, cert. ef. 1-1-95
HR 27-1993, f. & cert. ef. 10-1-93

Or. Admin. R. 410-129-0075 Face-to-Face Encounter Requirements for Fee-for-Service Clients

(1) For initial ordering of speech generating devices (SGD), an in-person, face-to-face encounter that is related to the primary reason the client requires the medical equipment or supplies must occur no more than six months prior to the start of services:

(a) The face-to-face encounter shall be conducted and documented by the treating physician (MD or DO) or an authorized non-physician practitioner (NPP);

(b) Authorized NPPs for SGD are nurse practitioners, clinical nurse specialists working in collaboration with a physician, or physician associate under the supervision of a physician;

(c) The physician or NPP conducting the face-to-face encounter shall document that the client is evaluated or treated for a condition that supports the need for the SGD ordered within six months prior to completing the written order for the equipment;

(d) If the NPP performing the face-to-face encounter does not have prescribing authority, the NPP shall communicate the clinical findings to the ordering physician;

(e) The ordering physician shall incorporate the clinical findings into a written or electronic document included in the client’s medical record.

(2) If a dually eligible client is evaluated for medical equipment or supplies under Medicare and transitions to Medicaid, the Medicare face-to-face encounter documentation shall meet the Medicaid face-to-face requirement.

(3) The durable medical equipment (DME) supplier shall maintain documentation of the qualifying face-to-face encounter and provide the documentation when the item requires PA or at the Division’s request.

(4) The table at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/DME_List_of_Specified_Covered_Items_updated_March_26_2015.pdf identifies the DME items subject to these face-to-face requirements.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 11-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 15-2020, temporary amend filed 03/26/2020, effective 03/26/2020 through 09/21/2020
DMAP 100-2018, adopt filed 11/06/2018, effective 11/06/2018
DMAP 30-2018, temporary adopt filed 05/17/2018, effective 05/17/2018 through 11/12/2018

Or. Admin. R. 410-129-0080 Prepayment Review (PPR) and Prior Authorization (PA) for payment

(1) Speech-language pathology, audiology, and hearing aid providers are subject to PPR or shall obtain PA for services exceeding 30 habilitative and 30 rehabilitative visits in a calendar year.

(2) Providers shall request PA as follows (see the SLP, Audiology and Hearing Aid Services Program Supplemental Information booklet for contact information):

(a) For Medically Fragile Children’s Unit (MFCU) clients, from the Authority’s MFCU;

(b) For clients enrolled in the fee-for-service Medical Case Management program, from the Medical Case Management contractor;

(d) For clients requiring visits in excess of 30 habilitative visits and 30 rehabilitative visits per calendar year.

(3) For services requiring PA, providers shall contact the responsible unit for authorization within five working days following initiation or continuation of services. The FAX or postmark date on the request shall be honored as the request date. It is the provider’s responsibility to obtain PA.

(4) For services subject to PPR and to ensure reimbursement of SLP services, beyond the initial evaluation, the SLP provider must submit all required supporting documentation:

(a) Upon submission of the first claim in a series of claims in each therapy plan of care as established by prescribing practitioner per OAR 410-129-0020 for claims subject to PPR;

(b) Request a PA within five working days following 30 rehabilitative or 30 habilitative visits within a calendar year if additional visits are necessary:

(A) PA requests dated within five working days may be approved retroactively to include services provided within five days prior to the date of the PA request;

(B) PA requests dated beyond five working days may not be authorized retroactively and if authorized shall be effective the date of the PA request. The Division recognizes the facsimile or postmark as the PA date of request.

(d) A PA is not required for Medicare-covered SLP services provided to dual-eligible clients (Medicare clients who are also Medicaid-eligible).

(5) If the service or item is subject to PPR or requiring PA, the provider shall follow and comply with PPR or PA requirements in these rules and the General Rules (OAR chapter 410, division 120) including but not limited to:

(a) The service is adequately documented (see OAR 410-120-1360 Requirements for Financial, Clinical and Other Records). Providers shall maintain documentation in the provider’s files to adequately determine the type, medical appropriateness, or quantity of services provided;

(b) The services provided are consistent with the information submitted when authorization was requested;

(d) The services are provided within the timeframe specified on the authorization of payment document; and

(e) Includes the PA number on all claims for services that require PA, or the Division shall deny the claim.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 40-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 57-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 85-2003, f. 11-25-03 cert. ef. 12-1-03
OMAP 39-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 27-1993, f. & cert. ef. 10-1-93
HR 11-1992, f. & cert. ef. 4-1-92
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91, Renumbered from 461-021-0310
AFS 7-1988, f. & cert. ef. 2-1-88
AFS 67-1985, f. 11-19-85, ef. 12-1-85
AFS 40-1984, f. 9-18-84, ef. 10-1-84
AFS 22-1984(Temp), f. & ef. 5-1-84
AFS 14-1984(Temp), f. & ef. 4-2-84
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 49-1982, f. 4-30-82, ef. 5-1-82
AFS 14-1982, f. 2-16-82, ef. 3-1-82

Or. Admin. R. 410-129-0085 Payment Methodology

(1) Speech-Language Pathology and Audiology outpatient services are priced based on RVU (Refer to OAR 410-120-1340(6)) and flat fee rates:

(a) Surgical procedures such as cochlear implants may be provided in a hospital or Ambulatory Surgical Center (ASC) (Refer to OAR 410-120-1340 (6) and (8));

(b) The Division reimburses inpatient hospital service under the DRG methodology, unless specified otherwise in the Division’s Hospital Services program administrative rules, chapter 410, division 125.

(2) The Division shall reimburse the following codes, using 75 percent of the Manufacturer’s Suggested Retail Price (MSRP). This is verifiable with quote, invoice, or bill from the manufacturer that clearly states the amount indicated is MSRP all require PA:

(a) E2599 (Accessory for SGD, not otherwise classified) and reimbursement shall be capped at $6,200;

(b) E2512 (SGD accessory, mounting system) and reimbursement shall be capped at $3,300;

(d) L8691(Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each) and reimbursement shall be capped at $1,888.94;

(e) L8692 (Auditory osseointegrated device, external sound processor, used without osseointegration, body worn) and reimbursement shall be capped at $2,045.20;

(f) L8693 (Auditory osseointegrated device abutment, any length, replacement only);

(g) L8694 (Audiory osseointegrated device, transducer/actuator, replacement only, each);

(h) V5281 (Assistive Listening Device (Ald) fm/dm system, monaural;

(i) V5282 (Ald fm/dm system, binaural);

(j) V5283 (Ald neck, loop induction receiver);

(k) V5284 (Ald fm/dm ear level receiver);

(L) V5285 (Ald fm/dm aud input receiver);

(m) V5286 (Ald blu tooth fm/dm receiver);

(n) V5287 (Ald fm/dm receiver, nos);

(o) V5288 (Ald fm/dm transmitter ald);

(p) V5289 (Ald fm/dm adapt/boot coupling device for receiver); and

(q) V5290 (Ald transmitter microphone).

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & ORS 414.025
DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 46-2021, amend filed 10/22/2021, effective 10/22/2021
DMAP 17-2021, temporary amend filed 05/05/2021, effective 05/05/2021 through 10/31/2021
DMAP 100-2018, adopt filed 11/06/2018, effective 11/06/2018
DMAP 30-2018, temporary adopt filed 05/17/2018, effective 05/17/2018 through 11/12/2018

Or. Admin. R. 410-129-0100 Medicare/Medicaid Claims

(1) When an individual not in managed care has both Medicare and Medicaid coverage, audiologists shall bill audiometry and all diagnostic testings to Medicare first. Medicare will automatically forward these claims to Medicaid. Refer to OAR 410-120-1210 (General Rules) for information on Division or CCO reimbursement.

(2) Audiologists shall bill all hearing aids and related services directly to the Division on an OHP 505. Payment authorization is required on most of these services.

(3) If Medicare transmits incorrect information to the Division, or if an out-of-state Medicare carrier or intermediary was billed, providers shall bill the Division using an OHP 505 form. If any payment is made by the Division, an adjustment request shall be submitted to correct payment, if necessary.

(4) Send all completed OHP 505 forms to the Division.

(5) Hearing aid dealers shall bill all services directly to the Division on a CMS-1500. Payment authorization is required on most services.

(6) When a client not in managed care has both Medicare and Medicaid coverage, speech-language pathologists shall bill services to Medicare first. Medicare will automatically forward these claims to Medicaid. Refer to OAR 410-120-1210 (General Rules) for information on Division or CCO reimbursement.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.034, 414.065, 414.329, 414.706 & 414.710
DMAP 19-2017, f. & cert. ef. 6-9-17
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
OMAP 57-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 12-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 11-1992, f. & cert. ef. 4-1-92
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91

Or. Admin. R. 410-129-0180 Procedure Codes

(1) Procedure codes listed in the Speech-Language Pathology, Audiology and Hearing Aid Services Program rules are intended for use by licensed speech-language pathologists, licensed audiologists, and certified hearing aid dealers.

(2) Physicians and nurse practitioners are subject to the administrative rules contained in the Division Medical-Surgical Services Program rules and shall bill the Division using the processes and procedure codes identified in those rules.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
HR 27-1993, f. & cert. ef. 10-1-93
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91

Or. Admin. R. 410-129-0200 Speech-Language Pathology Procedure Codes

(1) Inclusion of a current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) code in sections (2), (3) and (4) does not mean a code is covered. Refer to OAR 410-141-0480, 410-141-0500, and 410-141-0520 for information on coverage.

(2) The following Speech therapy services are subject to PPR when paired above the funding line on the HERC prioritized list (see OAR 410-141-0520), when visits have not exceeded the allowed 30 habilitative and 30 rehabilitative visits allowed in a calendar year:

(a) 92507 Treatment of speech, language, voice, communication and auditory processing disorder, individual; and

(b) 92508 Group, two or more individuals.

(3) PA is required for SLP services:

(a) When there is documented need for extended service, considering 60 minutes as the maximum length of a treatment session;

(b) When there is documented need for continuing rehabilitative or habilitative therapy, considering 30 habilitative and 30 rehabilitative visits in a calendar year;

(c) When requesting services for treatments that are below the funded line or not otherwise excluded from coverage per OAR 410-141-0480;

(d) For the following services:

(A) E2500 Speech generating device, digitized speech, using prerecorded messages, less than or equal to eight minutes recording time;

(B) E2502 Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than 20 minutes;

(C) E2504 Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than 40 minutes;

(D) E2506 Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time;

(E) E2508 Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device;

(F) E2510 Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access;

(G) E2511 Speech generating software program for personal computer or personal digital assistance;

(H) E2512 Accessory for speech generating device, mounting system;

(I) E2599 Accessory for speech generating device, not otherwise classified;

(J) L7520 Repair prosthetic device, labor component, for 15 minutes;

(K) L8510 Voice amplifier; and

(L) V5336 Repair, modification of augmentative communication system or device excluding adaptive hearing aid.

(4) Services not subject to PPR or PA:

(a) 92521 Evaluation of speech fluency (e.g., stuttering, cluttering);

(b) 92522 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria);

(c) 92523 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language);

(d) 92524 Behavioral and qualitative analysis of voice and resonance;

(e) 92597 Evaluation for use and fitting of voice prosthetic device to supplement oral speech;

(f) 92607 Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient, first hour;

(g) 92610 Evaluation of oral and pharyngeal swallowing function, limited to two per 12-month period;

(h) 92608 Each additional 30 minutes (List separately in addition to code for primary procedure);

(i) 92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording, limited to two per 12-month period;

(j) S9152 Speech therapy, re-evaluation, limited to four per 12-month period;

(k) A4649 Supplies for speech therapy, limited to two per calendar year not to exceed $4.75 each;

(L) 92526 Treatment of swallowing dysfunction and oral function for feeding;

(m) 92609 Therapeutic services for the use of speech-generating device, including programming and modification;

(n) L7510 Repair of prosthetic device, repair or replace minor parts;

(o) L8500 Artificial larynx, any type;

(p) L8501 Tracheostomy speaking valve;

(q) L8507 Tracheoesophageal voice prosthesis, patient inserted, any type, each;

(r) L8509 Tracheoesophageal voice prosthesis, inserted by a licensed health provider, any type;

(s) L8515 Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each; and

(t) L9900 Orthotic and prosthetic supply necessary or service component of another HCPCS L code (PA required).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 17-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 18-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 14-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 12-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 10-2002, f. & cert. ef. 4-1-02
OMAP 20-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 6-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 36-1994, f. 12-30-94, cert. ef. 1-1-95
HR 27-1993, f. & cert. ef. 10-1-93
HR 11-1992, f. & cert. ef. 4-1-92
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91

Or. Admin. R. 410-129-0220 Augmentative Communications System or Device

(1) Augmentative Communications System or Device and the necessary attachment equipment to bed or wheelchair are a covered benefit of the Division.

(2) The requested system or device shall be approved, registered, or listed as a medical device with the Food and Drug Administration.

(3) Criteria for coverage: Providers shall meet each of the following components and submit documentation to the Division with claims subject to PPR and with PA request for review:

(a) A physician’s statement of diagnosis and medical prognosis (not a prescription for an augmentative device) documenting the inability to use speech for effective communication as a result of the diagnosis;

(b) Reliable cognitive ability and a consistent motor response to communicate that can be measured by standardized or observational tools:

(A) Object permanence – ability to remember objects and realize they exist when they are not seen; and

(B) Means end – ability to anticipate events independent of those currently in progress – the ability to associate certain behaviors with actions that will follow.

(c) The client shall be assessed by a SLP and when appropriate an occupational therapist or physical therapist. The evaluation report shall include:

(A) A completed OHA 3047 form: Augmentative Communication Device Selection Report Summary (page 1) and required elements of the Formal Augmentative/Alternative Communication Evaluation (page 2). Attach additional pages required to complete information requested;

(B) An explanation of why this device is best suited for this client and why the device is the lowest level that will meet basic functional communication needs;

(D) A therapy treatment plan with the identification of the individual responsible to program the device and monitor and reevaluate on a periodic basis.

(d) Providers send requests for augmentative communications systems or devices to the Division; and

(e) The manufacturer’s MSRP and the vendor’s acquisition cost quotations for the device shall accompany each request including where the device is to be shipped.

(4) The Division shall reimburse for the lowest level of service that meets the medical need.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & ORS 414.065
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 3-2011, f. 3-23-11, cert. ef. 3-25-11
DMAP 26-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11
OMAP 59-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 36-1994, f. 12-30-94, cert. ef. 1-1-95
HR 11-1992, f. & cert. ef. 4-1-92
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91
HR 40-1990(Temp), f. & cert. ef. 11-15-90

Or. Admin. R. 410-129-0240 Audiologist and Hearing Aid Procedure Codes

(1) Inclusion of a CPT/HCPCS code on the following does not mean that a code is covered. Refer to OAR 410-120-1280 and OAR 410-141-3565 for information on coverage.

(2) The following are Audiologist and hearing aid procedure codes:

(a) 92553 – Pure tone audiometry, air and bone, limited to one per calendar year;

(b) 92557 – Comprehensive audiometry threshold evaluation and speech recognition includes pure tone, air and bone, and speech threshold and discrimination. Also includes testing necessary to determine feasibility of amplification;

(c) 92590 – Hearing aid examination and selection, monaural may include sound field speech reception tests, speech discrimination tests, determination of appropriate style of hearing aid and to determine if the ear may receive amplification;

(d) 92591 – Hearing aid examination and selection, binaural may include sound field speech reception tests, speech discrimination tests, determination of appropriate style of hearing aid, and which ear may receive amplification;

(e) 92592 – Monaural hearing aid inspection and battery check. The aid is cleaned, and the power and clarity are checked using a special stethoscope, which attaches to the hearing aid.

(f) 92593 – Binaural hearing aids inspection and battery check. The aids are cleaned, and the power and clarity are checked using a special stethoscope, which attaches to the hearing aids.

(g) V5261 – Hearing aid, digital, binaural and behind the ear requires Prior Authorization (PA);

(h) V5011 – Fitting, orientation, checking of hearing aid includes adjusting aid to the wearer, instructions to wearer, and follow-up care, and requires PA prior to provision of services;

(i) V5275 – Ear impressions made to obtain a hearing device specified for the individual, each.

(j) V5160 – Hearing aid dispensing fee, binaural, requires PA prior to providing services;

(k) V5181 – Hearing aid, contralateral routing device, monaural, behind the ear (bte);

(L) V5200 – Hearing aid dispensing fee, contralateral, monaural, requires PA prior to providing services;

(m) V5240 – Hearing aid dispensing fee, two devises, contralateral routing system, binaural, requires PA prior to providing services;

(n) V5241 – Hearing aid dispensing fee, monaural hearing aid, any type, requires PA prior to providing services;

(o) V5110 – Body warn hearing aid dispensing fee, bilateral.

(p) V5020 – The conformity evaluation is to confirm that the hearing aid is meeting the needs of the patient.

(q) 95992 – Canalith repositioning, treatment for vertigo, per day.

(3) Special otorhinolaryngologic services codes only apply to services for cochlear implants. These services include medical diagnosis evaluation by the otology physician:

(a) 92601 – Diagnostic analysis of cochlear implant, patient under seven (7) years of age, with programming;

(b) 92602 – Analysis and reprogramming of inner ear (cochlear) implant, younger than seven 7 years of age;

(d) 92604 – Analysis and reprogramming of inner ear (cochlear) implant, age seven 7 years or older;

(e) 92626 – Evaluation of auditory rehabilitation status, first hour;

(f) 92627 – Each additional 15 minutes;

(g) 92630 – Auditory rehabilitation; pre-lingual hearing loss;

(h) 92633 – Post-lingual hearing loss;

(i) L8614 – Cochlear device/system (only reimbursed to hospitals);

(j) L8615 – Headset/headpiece for use with cochlear implant device, replacement;

(k) L8616 – Microphone for use with cochlear implant device, replacement;

(L) L8617 – Transmitting coil for use with cochlear implant device, replacement;

(m) L8618 – Transmitter cable for use with cochlear implant device, replacement;

(n) L8619 – Cochlear implant external speech processor, replacement;

(o) L8621 – Zinc air battery for use with cochlear implant device, replacement, each (maximum of 420 batteries per 12 months);

(p) L8622 - Alkaline battery for use with cochlear implant device, replacement, each (maximum of 420 batteries per 12 months);

(q) L8623 – Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each (maximum of two rechargeable per 12 months);

(r) L8624 –Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each (maximum of two rechargeable per 12 months);

(s) L7510 – Repair of prosthetic device, repair or replace minor parts, requires PA prior to providing services;

(t) L7520 – Repair prosthetic device, labor component, for 15 minutes, requires PA prior to providing services.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 46-2021, amend filed 10/22/2021, effective 10/22/2021
DMAP 17-2021, temporary amend filed 05/05/2021, effective 05/05/2021 through 10/31/2021
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
OMAP 18-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 14-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 10-2002, f. & cert. ef. 4-1-02
OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 27-1993, f. & cert. ef. 10-1-93
HR 11-1992, f. & cert. ef. 4-1-92
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91

Or. Admin. R. 410-129-0260 Hearing Aids and Hearing Aid Technical Service and Repair

(1) The provider shall bill the Division for hearing aids at the provider’s acquisition cost and shall be reimbursed at that rate. For purposes of this rule, acquisition cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer or supplier plus any shipping or postage.

(2) The provider shall submit history of hearing aid use and an audiogram when requesting Prior Authorization (PA) for hearing aids.

(3) Procedure codes are the following:

(a) 92594 – Electroacoustic evaluation for hearing aid, monaural;

(b) 92595 – Electroacoustic evaluation for hearing aid, binaural;

(d) V5014 – Repair/modification of hearing aid, requires PA;

(e) V5266 – Hearing aid batteries, limited to 60 individual batteries per calendar year;

(f) V5264 – Ear mold/insert, not disposable, any type, requires PA;

(g) V5274 – Assistive listening device, not otherwise specified, requires PA;

(h) V5030 – Hearing aid, monaural, body worn, air conduction, requires PA;

(i) V5040 – Hearing aid, monaural, body worn, bone conduction, requires PA;

(j) V5050 – Hearing aid, monaural, in the ear, requires PA;

(k) V5060 – Hearing aid, monaural, behind the ear, requires PA;

(L) V5130 – Hearing aid, binaural, in the ear, requires PA;

(m) V5140 – Hearing aid, binaural, behind the ear, requires PA;

(n) V5171 – Hearing aid, contralateral routing device, monaural, ITE, requires PA;

(o) V5180 – Hearing aid, contralateral routing device, monaural, BTE, requires PA;

(p) V5211 – Hearing aid, contralateral routing system, binaural, ITE- requires PA;

(q) V5221 – Hearing aid, contralateral routing system, binaural, BTE- requires PA;

(r) V5246 – Hearing aid, digitally programmable analog, monaural, ITE, requires PA;

(s) V5247 – Hearing aid, digitally programmable analog, monaural, (BTE) requires PA;

(t) V5252 – Hearing aid, digital programmable, binaural, ITE, requires PA;

(u) V5253 – Hearing aid, digital programmable, binaural, BTE, requires PA;

(v) V5256 – Hearing aid, digital, monaural, ITE, requires PA;

(w) V5257 – Hearing aid, digital, monaural, BTE, requires PA.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
OMAP 18-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 12-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 10-2002, f. & cert. ef. 4-1-02
OMAP 39-2001, f. 9-24-01, cert.e f. 10-1-01
OMAP 20-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 27-1993, f. & cert. ef. 10-1-93
HR 11-1992, f. & cert. ef. 4-1-92
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91

Or. Admin. R. 410-129-0280 Hearing Testing for Diagnostic Purposes on Physician’s Referral Only

(1) A physician's referral is required for the tests shown in this rule. The tests may only be performed and billed by a licensed audiologist or a licensed physician.

(2) Procedure codes are the following:

(a) 92541 – Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording;

(b) 92542 – Positional nystagmus test, minimum of four positions, with recording;

(c) 92543 – Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) with recording;

(d) 92544 – Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording;

(e) 92545 – Oscillating tracking test, with recording;

(f) 92546 – Sinusoidal vertical axis rotational testing;

(g) 92547 – Use of vertical electrodes in any or all the above tests counts as one additional test;

(h) 92548 – Test for balance and posture;

(i) 92551 – Screening test, pure tone, air only;

(j) 92552 – Pure tone audiometry (threshold); air only;

(k) 92555 – Speech audiometry; threshold only;

(L) 92556 – With speech recognition;

(m) 92562 – Loudness balance test, alternate binaural or monaural;

(n) 92563 – Tone decay test;

(o) 92564 – Short increment sensitivity index (SISI);

(p) 92565 – Stenger test, pure tone;

(q) 92567 – Tympanometry;

(r) 92568 – Acoustic reflex testing; threshold;

(s) 92569 – Acoustic reflex testing; decay;

(t) 92571 – Filtered speech tests;

(u) 92572 – Staggered spondaic word test;

(v) 92575 – Sensorineural acuity test, test to assess hearing loss using different tone pitches;

(w) 92576 – Synthetic sentence identification test;

(x) 92577 – Stenger test, speech;

(y) 92579 – Visual reinforcement audiometry (VRA);

(z) 92582 – Conditioning play audiometry;

(aa) 92583 – Select picture audiometry;

(bb) 92584 – Electocochleography, test to assess electrical potentials generated in the inner ear as a result of sound stimulation;

(cc) 92585 – Auditory evoked potentials for evoked response audiometry or testing of the central nervous system, comprehensive;

(dd) 92586 – Auditory evoked potentials for evoked response audiometry or testing of the central nervous system, limited;

(ee) 92587 – Evoked Otacoustic Emissions, - limited (single stimulus level, either transient or distortion products);

(ff) 92588 – Evoked Otacoustic Emissions, comprehensive or diagnostic evaluation (comparison of transient or distortion product otoacoustic emissions at multiple levels and frequencies);

(gg) 92620 – Auditory function 60 minutes, evaluation of hearing function brain responses, first hour

(hh)92621 – Auditory function +15 minutes, evaluation of hearing function brain responses, each additional 15 min

(ii) 92589 Central auditory function tests (specify).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
OMAP 18-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 20-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 36-1999, f. & cert. ef. 10-1-99
HR 27-1993, f. & cert. ef. 10-1-93
HR 11-1992, f. & cert. ef. 4-1-92
HR 5-1991, f. 1-18-91, cert. ef. 2-1-91

Division 130 MEDICAL-SURGICAL SERVICES

Or. Admin. R. 410-130-0000 Foreword

(1) The Division Medical-Surgical Services rules are designed to assist medical-surgical providers to deliver medical services and prepare health claims for clients with Medical Assistance Program coverage. Providers must follow the Division rules in effect on the date of service.

(2) The Division enrolls only the following types of providers as performing providers under the Medical-Surgical program:

(a) Doctors of medicine, osteopathy and naturopathy;

(b) Podiatrists;

(d) Licensed Physician associates;

(e) Nurse practitioners;

(f) Laboratories;

(g) Family planning clinics;

(h) Social workers (for specified services only);

(i) Licensed Direct entry midwives;

(j) Portable x-ray providers;

(k) Ambulatory surgical centers;

(l) Chiropractors;

(m) Licensed Dieticians (for specified service only);

(n) Registered Nurse First Assistants;

(o) Certified Nurse Anesthetists;

(p) Clinical Pharmacists;

(q) Birthing Centers;

(r) Licensed Genetic Counselor.

(3) For clients enrolled in a managed care plan, contact the client's plan for coverage and billing information.

(4) The Medical-Surgical Services rules contain information on policy, special programs, prior authorization, and criteria for some procedures. All Division rules are intended to be used in conjunction with the General Rules for Oregon Medical Assistance Programs (OAR 410 division 120) and the Oregon Health Plan (OHP) Administrative Rules (OAR 410 division 141).

(5) The Health Services Commission's Prioritized List of Health Services is found on their website at: www.oregon.gov/OHA/HPA/CSI-Herc/Pages/Prioritized-List.aspx.

History

Statutory/Other Authority: ORS 413.042 & 676.730
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 12-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 51-2023, amend filed 06/30/2023, effective 06/30/2023
DMAP 47-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
HR 23-1997, f. & cert. ef. 10-1-97
HR 6-1994, f. & cert. ef. 2-1-94
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0500
AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0001
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86
AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, cert. ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, cert. ef. 6-30-82 for remaining AFS Branch offices
AFS 36-1981, f. 6-29-81, cert. ef. 7-1-81
PWC 868, f. 12-30-77, cert. ef. 2-1-78

Or. Admin. R. 410-130-0005 Federally Qualified Primary Care Provider

(1) Section 1202 of the Affordable Care Act (ACA) amended sections 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of the Social Security Act to require increased Medicaid payment for primary care services to qualified providers for calendar years 2013 and 2014 as specified in these rules.

(2) Federally Qualified Primary Care Services are designated as:

(a) Evaluation and Management (E&M) Current Procedural Terminology (CPT) codes 99201 through 99499; and

(b) Vaccine administration CPT codes 90460, 90461, 90471, 90472, 90473 and 90474, or their successor codes; and

(3) To qualify for the increased payment, the individual physician must attest that:

(a) The physician has a primary practice in family medicine, general internal medicine, or pediatric medicine; and

(b) One or both of the following are true:

(A) The physician is Board-certified in a specialty or subspecialty of family medicine, general internal medicine, or pediatric medicine by one of the following boards:

(i) The American Board of Medical Specialties (ABMS);

(ii) The American Osteopathic Association (AOA);

(iii) The American Board of Physician Specialties (ABPS);

(B) The physician can demonstrate that at least 60 percent of the procedure codes billed and paid in Medicaid claims were qualifying primary care codes described in section 2 of this rule.

(i) Over the previous calendar year, if billings exist for this time period; or

(ii) Over the previous month, if billings do not exist for the previous calendar year.

(4) To qualify for the increased payment, a Physician Associate (PA) or Nurse Practitioner (NP) must attest that they work under the direct supervision of a Physician who:

(a) Qualifies for increased primary care payments as described in these rules; and

(b) Assumes professional responsibility for the services rendered by the PA or NP.

(5) Providers seeking the reimbursement increase from the Division of Medical Assistance Programs (Division) must self-attest with the Division. Providers, not enrolled with the Division, seeking the increase from OHP health plans (MCO or CCO), must self-attest with the applicable MCO or CCO.

(6) Reimbursement: Effective for dates of service on or after January 1, 2013, the Division shall reimburse primary care providers as follows:

(a) Federally qualified primary care providers as described in this rule at the rate specified in OAR 410-120-1340(6)(C)(ii); or

(b) Other primary care providers, including potentially qualified providers who do not self-attest to the Division as described in part (3) of this rule, at the rate specified in OAR 410-120-1340(6)(C)(iii).

(7) Annual review of qualifying providers: The Division will review a statistically valid sample of providers to determine whether they satisfy the criteria described in (3) and (4) of these rules. Providers reviewed who do not satisfy the criteria will be required to reimburse the Division for the difference between the rate they should have received according to OAR 410-120-1340(6)(C)(iii) and enhanced rate in OAR 410-120-1340(6)(C)(ii). The sample will include the following providers:

(a) Physicians who have self-attested to qualifying for the increased rate; and

(b) Providers who have self-attested that they are under the direct supervision of a qualified physician.

(8) Supplemental information on primary care reimbursement under the Affordable Care Act is available at http://www.oregon.gov/OHA/HSD/OHP/Pages/Providers.aspx.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.025 & 414.065
DMAP 13-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 48-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 49-2013, f. & cert. ef. 9-25-13
DMAP 14-2013(Temp), f. & cert. ef. 3-29-13 thru 9-25-13

Or. Admin. R. 410-130-0015 Doula Services

(1) The primary purpose of providing birth doula services as a member of the birthing team is to optimize birth outcomes, including prevention of preterm births, fewer neonatal intensive care admissions, reduced Caesarean sections, reduced epidural use, and improved member experience of birthing care. These services are provided during the prenatal, labor and delivery, and postpartum phases of the member’s pregnancy. Pregnant women or pregnant persons experiencing health disparities are expected to benefit most from birth doula services, including the following:

(a) A pregnant woman or pregnant person with a racially or ethnically diverse background including, Black/African American, Asian, Native Hawaiian/Pacific Islander, Native American, Latino/Latina/Latinx, multicultural or multiracial;

(b) A pregnant woman or pregnant person experiencing houselessness;

(d) A pregnant woman or pregnant person who has limited to no family or partner support;

(e) A pregnant woman or pregnant person who is under the age of 21.

(2) Birth doula providers shall meet the following requirements at the time services are provided:

(a) Shall be enrolled with the Authority as a Traditional Health Worker (THW) pursuant to OAR 950-060-0000.

(b) Shall be certified as a birth doula pursuant to OAR 950-060-0040.

(3) Birth doula providers shall document services provided for each encounter. The birth doula’s record shall include the dates of service, a brief description of education or services provided, assessment of any client or member needs beyond routine care, and any referrals made. The goal of documentation is to verify services were provided and facilitate communication with other members of the birthing team.

(4) The Authority shall pay for birth doula services for any woman or pregnant person whose benefit package covers labor and delivery.

(5) Payment for birth doula services:

(a) No pre-authorization is required;

(b) For a member enrolled in Fee for Service (FFS) medical programs:

(c) To be considered for payment, birth doula services shall be billed on a professional claim and shall include the unique Medicaid modifier of HD or 22 appended to the appropriate obstetrical code;

(d) Birth doula care shall be billed as a global birth doula package. A global package shall include at a minimum two (2) prenatal face-to-face visits, care during the labor and delivery phase, and two (2) postpartum face-to-face visits;

(e) Up to four (4) additional support visits to be billed separately beyond the global birth doula package. The additional support visits may occur anytime, in any combination of prenatal and postpartum visits, continuing for twelve (12) months following the end of the pregnancy.

(f) Itemized billing, i.e., billing the day-of-delivery as a standalone and billing separate prenatal and postpartum visits, is allowed in extenuating circumstances. Extenuating circumstances include but are not limited to when the primary birth doula is not able to attend the delivery and a backup birth doula provides services or when a mother is late to care making scheduling two (2) prenatal face-to-face visits impossible:

(A) When appropriate due to extenuating circumstances, services rendered by multiple birth doulas for the same pregnancy may be itemized for billing;

(B) Reimbursement of itemized services, regardless of the number of birth doulas serving the member, may not exceed the global package total and up to four (4) additional support visits.

(g) Billing for birth doula services shall include:

(A) Using HCPCS T1033 with HD modifier one time for a global birth doula package (delivery with two (2) prenatal and two (2) postpartum visits);

(B) Using HCPCS T1033 with 22 modifier for doula service day of delivery only. T1033 with no modifier for support visit (two (2) prenatal and two (2) postpartum visits);

(D) Claim only one global birth doula package per pregnancy. A global birth doula package may not be billed together with any of the itemized birth doula services codes for the same pregnancy.

(h) Birth doula services may only be billed once per pregnancy. Multiples (i.e., twins, triplets) are not eligible for additional payment;

(i) Only an enrolled birth doula, provider type designation 13/600, may be the rendering provider for birth doula services.

(j) For a member enrolled in CCO medical programs, payment shall be per OARs governing CCO provider payment.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 1-2025, amend filed 01/07/2025, effective 01/07/2025
DMAP 91-2024, amend filed 05/22/2024, effective 05/22/2024
DMAP 57-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 33-2021, temporary amend filed 07/23/2021, effective 07/23/2021 through 01/18/2022
DMAP 19-2018, amend filed 04/02/2018, effective 04/02/2018
DMAP 39-2017, temporary amend filed 10/03/2017, effective 10/04/2017 through 04/04/2018
DMAP 38-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 17-2017(Temp), f. 5-24-17, cert. ef. 5-25-17 thru 10-27-17
DMAP 13-2017(Temp), f. 4-28-17, cert. ef. 5-1-17 thru 10-27-17
DMAP 73-2013, f. 12-31-13, cert. ef. 1-1-14

Or. Admin. R. 410-130-0160 Codes

(1) ICD-10-CM Diagnosis Codes:

(a) Always use the principal diagnosis code in the first position to the highest degree of specificity. List additional diagnosis codes if the claim includes charges for services that relate to the additional diagnoses. However, it is not necessary to include more than one diagnosis code per procedure code;

(b) Diagnosis codes are required on all billings including those from independent laboratories and portable radiology including nuclear medicine and diagnostic ultrasound providers;

(c) Always supply the ICD-10-CM diagnosis code to ancillary service providers when prescribing services, equipment, and supplies.

(2) CPT and HCPCS Codes:

(a) Use only codes from the current year for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes;

(b) Effective January 1, 2005, HIPAA regulations prohibit the use of a grace period for codes deleted from CPT or HCPCS. In the past the grace period was from January 1 through March 31;

(c) The division may consider reimbursement for CPT category III codes included under the following headings: Adaptive Behavior Assessments, Adaptive Behavior Treatment, and Exposure Adaptive Behavior Treatment With Protocol Modification. All CPT category II (codes with fifth character of “F”) and all other category III codes (codes with fifth character “T”) are not Division of Medical Assistance Programs’ (Division) covered services;

(d) Use the most applicable CPT or HCPCS code. Do not fragment coding when services can be included in a single code (see the “Bundled Services” section of this rule). Do not use both CPT and HCPCS codes for the same procedure. This is considered duplicate billing.

(3) The Medical-Surgical Service rules list the HCPCS/CPT codes that require authorization or have limitations. The Health Evidence Review Commission’s Prioritized List of Health Services (OAR 410-141-3830) determines covered services.

(4) For determining the appropriate level of service code for Evaluation and Management services, read the definitions in the CPT and HCPCS codebook. Use the definitions to verify level of service, especially for office visits. Unless otherwise specified in the Medical-Surgical provider rule, use the guidelines from CPT and HCPCS.

(5) Bundled Services: Reimbursements for some services are “bundled” into the payment for another service. The Division does not make separate payment for bundled services and clients may not be billed for bundled services. The Division’s Not Covered/Bundled Services rule, OAR 410-130-0220, provides more information regarding bundled services.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 73-2023, minor correction filed 08/22/2023, effective 08/22/2023
DMAP 71-2023, minor correction filed 08/19/2023, effective 08/19/2023
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 15-2015, f. 3-27-15, cert. ef. 4-1-15
DMAP 74-2014(Temp), f. 12-9-14, cert. ef. 1-1-15 thru 6-29-15
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 10-1996, f. 5-31-96, cert. ef. 6-1-96
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
HR 23-1992, f. 7-31-92, cert. ef. 8-1-92
HR 8-1992, f. 2-28-92, cert. ef. 3-1-92
HR 2-1992, f. & cert. ef. 1-2-92
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0610
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89

Or. Admin. R. 410-130-0180 Drugs

(1) The Division of Medical Assistance Programs’ (Division) Medical-Surgical Services Program reimburses practitioners for drugs only when administered by the practitioner in the office, clinic or home settings. The Division does not reimburse practitioners for drugs that are self-administered by the client, except for contraceptives such as birth control pills, spermicides and patches:

(a) Use an appropriate Current Procedural Terminology (CPT) therapeutic injection code for administration of injectables;

(b) Use an appropriate Healthcare Common Procedure Coding System (HCPCS) code for the specific drug. Do not bill for drugs under code 99070; The Division requires both the NDC number and HCPCS codes on all claim forms.

(c) When there is no specific HCPCS code for a drug or biological, use an appropriate unlisted code from the list below and bill at acquisition cost (purchase price plus postage):

(A) J3490;

(B) J3590;

(D) J7699;

(E) J7799;

(F) J8499;

(G) J8999;

(H) J9999;

(I) Include the name of the drug, National Drug Code (NDC) number and dosage.

(2) Do not bill for local anesthetics; reimbursement is included in the payment for the tray and/or procedure.

(3) For codes requiring prior authorization and codes that are Not Covered/Bundled, refer to OAR 410-130-0200 Table 130-0200-1 and OAR 410-130-0220 Table 130-0220-1.

(4) Not covered services and supplies include:

(a) Laetrile;

(b) Home pregnancy kits and products designed to promote fertility;

(c) Dimethyl sulfoxide (DMSO), except for instillation into the urinary bladder for symptomatic relief of interstitial cystitis;

(d) Infertility drugs;

(e) Sodium hyaluronate and Synvisc.

(5) Follow criteria outlined in the following:

(a) Billing Requirements — OAR 410-121-0150;

(b) Brand Name Pharmaceuticals — OAR 410-121-0155;

(d) Drugs and Products Requiring Prior Authorization — OAR 410-121-0040;

(e) Drug Use Review — OAR 410-121-0100;

(f) Participation in Medicaid’s Drug Rebate Program — OAR 410-121-0157.

(A) The Division cannot reimburse providers for a drug unless the drug manufacturer has signed an agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicaid Drug Rebate Program.

(B) To verify that a drug manufacturer participates in the Medicaid Drug Rebate Program, visit the CMS website below to verify that the first five digits of the NDC number (labeler code) are listed as a participating drug company: https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/data/index.html.

(6) Clozaril/Clozapine therapy:

(a) Clozapine is covered only for the treatment of clients who have failed therapy with at least two anti-psychotic medications;

(b) Clozapine supervision is the management and record keeping of clozapine dispensing as required by the manufacturer of clozapine. This is part of an evaluation and management service conducted by the appropriately licensed prescribing medical practitioner;

[ED. NOTE: Tables referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 49-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 27-2013, f. & cert. ef. 6-25-13
DMAP 58-2012(Temp), f. 12-27-12, cert. ef. 12-28-12 thru 6-25-13
DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 52-2002, f. & cert. ef. 10-1-02
OMAP 39-2002, f. 9-13-02, cert. ef. 9-15-02
OMAP 33-2002, f. & cert. ef. 8-1-02
OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 10-1996, f. 5-31-96, cert. ef. 6-1-96
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 43-1991, f. & cert. ef. 10-1-91
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0620
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89

Or. Admin. R. 410-130-0190 Tobacco Cessation

(1) Tobacco treatment interventions may include one or more of these services: basic, intensive, and telephone calls.

(2) Basic tobacco cessation treatment includes the following services:

(a) Ask — systematically identify all tobacco users — usually done at each visit;

(b) Advise — strongly urge all tobacco users to quit using;

(d) Assist — with brief behavioral counseling, treatment materials and the recommendation/prescription of tobacco cessation therapy products (e.g., nicotine patches, oral medications intended for tobacco cessation treatment and gum);

(e) Arrange — follow-up support and/or referral to more intensive treatments, if needed.

(3) When providing basic treatment, include a brief discussion to address client concerns and provide the support, encouragement, and counseling needed to assist with tobacco cessation efforts. These brief interventions, less than 6 minutes, generally are provided during a visit for other conditions, and additional billing is not appropriate.

(4) Intensive tobacco cessation treatment is on the Health Services Commission's Prioritized List of Health Services and is covered if a documented quit date has been established. This treatment is limited to ten sessions every three months. Treatment is reserved for those clients who are not able to quit using tobacco with the basic intervention measures.

(5) Intensive tobacco cessation treatment includes the following services:

(a) Multiple treatment encounters (up to ten in a 3 month period);

(b) Behavioral and tobacco cessation therapy products (e.g., nicotine patches, oral medications intended for tobacco cessation treatment and gum);

(6) Telephone calls: the Division may reimburse a telephone call intended as a replacement for face-to-face contact with clients who are in intensive treatment as it is considered a reasonable adjunct to, or replacement for, scheduled counseling sessions:

(a) The call must last six to ten minutes and provides support and follow-up counseling;

(b) The call must be conducted by the provider or other trained staff under the direction or supervision of the provider;

(7) Diagnosis Code ICD-10-CM (F17.200-F17.299; Nicotine Dependence):

(a) Use as the principal diagnosis code when the client is enrolled in a tobacco cessation program or if the primary purpose of the visit is for tobacco cessation services;

(b) Use as a secondary diagnosis code when the primary purpose of this visit is not for tobacco cessation or when the tobacco use is confirmed during the visit.

(8) Billing Information: Coordinated care organizations and managed care plans may have tobacco cessation services and programs. This rule does not limit or prescribe services a Prepaid Health Plan provides to clients receiving OHP benefits.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 15-1998, f. & cert. ef. 5-1-98
HR 36-1992, f. & cert. ef. 12-1-92

Or. Admin. R. 410-130-0200 Prior Authorization

(1) For fee-for-service (FFS) clients, Prior Authorization (PA) is required for all procedure codes listed in Table 130-0200-1. PA is required in all settings unless otherwise indicated. See indicators in table heading. For details on where to obtain PA, download a copy of the Prior Authorization Handbook at: http://www.oregon.gov/oha/HSD/OHP/Tools/Prior%20Authorization%20Handbook.pdf.

(2) Providers must obtain PA from the OHP payer, either FFS or CCO; that shall be responsible for payment at the time the service is delivered.

(3) The Division shall authorize for the level of care or type of service that meets the client’s medical need consistent with the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List) and guideline notes, as referenced in OAR 410-141-3830.

(4) Codes for which medical need has not been specified by the HERC shall be authorized based on medical appropriateness as the term is defined in OAR 410-120-0000.

(5) PA requests for coverage of planned births taking place in a clinic, birth center or home setting will be referred to as community births or as out-of-hospital births. To obtain PA for coverage of these services, providers must meet the requirements and submit the forms and required supporting documentation as described in the Planned Community Births (Out-of-Hospital Births) Prior Authorization and Billing Guide, effective September 2021 available at: https://www.oregon.gov/oha/HSD/OHP/Tools/Planned-Community-Birth-Guide.pdf.

(a) Due to the current COVID-19 public health emergency and surge in Oregon cases impacting hospital capacities, initial documentation to assess pregnancy risk per OAR 410-130-0240 must be received by the Division no later than 38 weeks, 0 days gestation, through the COVID health emergency or until rescinded or revised by the Division;

(b) Documentation requirements reflecting prior prenatal care must be met. Requests for ongoing documentation to continue the support of assessment of pregnancy risk must also be met per OAR 410-120-1320(2)(3).

(6) PA is not required:

(a) For clients with both Medicare and Medical Assistance Program coverage, and the service is covered by Medicare. However, PA is still required for bariatric surgeries and most transplants, even if they are covered by Medicare;

(b) For kidney and cornea transplants unless they are performed out-of-state;

(d) For hospital admissions unless the procedure requires PA.

(7) A second opinion may be requested by the Division or the contractor before PA is given.

(8) Treating and performing practitioners are responsible for obtaining PA.

(9) PA documentation must be complete and legible.

(10) PA shall be considered based on the documentation submitted.

(11) Refer to Table 130-0200-1 for all services and procedures requiring PA.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 54-2025, amend filed 06/25/2025, effective 06/25/2025
DMAP 111-2024, amend filed 07/11/2024, effective 07/11/2024
DMAP 59-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 35-2021, temporary amend filed 09/03/2021, effective 09/03/2021 through 03/01/2022
DMAP 47-2020, amend filed 09/16/2020, effective 09/18/2020
DMAP 12-2020, temporary amend filed 03/23/2020, effective 03/23/2020 through 09/18/2020
DMAP 89-2018, amend filed 08/28/2018, effective 09/09/2018
DMAP 15-2018, temporary amend filed 03/14/2018, effective 03/14/2018 through 09/09/2018
DMAP 89-2015, f. 12-30-15, cert. ef. 1-1-16
DMAP 68-2015(Temp), f. 11-25-15, cert. ef. 12-1-15 thru 5-28-16
DMAP 13-2015, f. & cert. ef. 3-10-15
DMAP 55-2014(Temp), f. 9-26-14, cert. ef. 10-1-14 thru 3-30-15
DMAP 43-2014, f. & cert. ef. 7-8-14
DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 15-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 12-2008, f. 4-29-08, cert. ef. 5-1-08
DMAP 27-2007(Temp), f. & cert. ef. 12-20-07 thru 5-15-08
DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 50-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
HR 24-1991, f. & cert. ef. 6-18-91
HR 17-1991(Temp), f. 4-12-91, cert. ef. 5-1-91
HR 44-1990, f. & cert. ef. 11-30-90
HR 25-1990(Temp), f. 8-31-90, cert. ef. 9-1-90
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0630
AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0045
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86
AFS 38-1986, f. 4-29-86, cert. ef. 6-1-86
AFS 23-1986, f. 3-19-86, cert. ef. 5-1-86
AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, cert. ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, cert. ef. 6-30-82 for remaining AFS branch offices
AFS 65-1980, f. 9-23-80, cert. ef. 10-1-80
AFS 868, f. 12-30-77, cert. ef. 2-1-78

Or. Admin. R. 410-130-0220 Not Covered/Bundled Services/Not Valid

(1) Under the Division’s Fee-for-Service Medical-Surgical program, no payment shall be made for (a) and (b) of this section except in accordance with applicable exceptions as defined in administrative rule:

(a) For the purposes of this rule, the billing codes that are not covered shall be:

(A) Services below the funding line or otherwise specified as not covered on the Health Evidence Review Commission (HERC) Prioritized List of Health Services as referenced in OAR 410-141-3830;

(B) Services specified in OAR 410-120-1200;

(C) For Ambulatory Surgical Centers, services listed on Medicare’s ASC Covered Surgical Procedures file addendum EE, Surgical Procedures to Be Excluded from Payment in ASCs as referenced in OAR 410-120-1340.

(b) For the purposes of this rule, the billing codes that are not eligible for separate reimbursement shall be:

(A) Services listed in Medicare’s Physician Fee Schedule RVU file as referenced in OAR 410-120-1340 that have a code status of B (Bundled Code) or P (Bundled/Excluded Codes). Services billed with billing codes 98960-98962 are excepted from this subsection and may be reimbursed separately;

(B) For Ambulatory Surgical Centers, services listed on Medicare’s ASC Covered Surgical Procedures file as referenced in OAR 410-120-1340 that have payment indicator N1 (Packaged service) or L1 (Packaged item/service);

(C) Certain services listed in the Medicare’s Physician Fee Schedule RVU file that have a code status of I (Not valid for Medicare purposes) as referenced in OAR 410-120-1340. Services with this status code are eligible for separate reimbursement only when listed on the Authority’s published fee schedule;

(D) Services listed in the Medicare’s Physician Fee Schedule RVU file that have a code status of M (Measurement codes) or Q (Therapy functional information code) as referenced in OAR 410-120-1340.

(2) In the event that a covered Fee-for-Service Medical-Surgical program service does not have a payment methodology specified in OAR 410-120-1340 or in other program specific rules, the division may set a reasonable rate for the service’s billing codes or designate that the service’s billing codes do not pay separately. No reimbursement shall be made for services designated to not pay separately.

(3) Nothing in this rule is intended to prevent payment for services by CCOs or in programs other than the Division’s Fee-for-Service Medical-Surgical program. See applicable rules for CCO payment and other programs.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 63-2022, amend filed 06/28/2022, effective 06/28/2022
DMAP 6-2018, amend filed 01/31/2018, effective 02/01/2018
DMAP 17-2016, f. 4-28-16, cert. ef. 5-1-16
DMAP 13-2016(Temp), f. & cert. ef. 3-4-16 thru 8-30-16 DMAP 63-2015, f. 10-29-15, cert. ef. 11-1-15; DMAP 30-2015(Temp), f. & cert. ef. 5-29-15 thru 11-24-15; DMAP 13-2015, f. & cert. ef. 3-10-15
DMAP 84-2014(Temp), f. & cert. ef. 12-24-14 thru 3-30-15
DMAP 55-2014(Temp), f. 9-26-14, cert. ef. 10-1-14 thru 3-30-15
DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 15-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 45-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 37-1999, f. & cert. ef. 10-1-99
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 30-1998, f. & cert. ef. 9-1-98
OMAP 16-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 21-1991, f. 4-16-91, cert. ef. 5-1-91
HR 14-1991(Temp), f. & cert. ef. 3-7-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0640
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89

Or. Admin. R. 410-130-0225 Teaching Physicians

(1) Supervising faculty physicians in a teaching hospital may not bill the Division of Medical Assistance Programs (Division) on a CMS-1500 or 837P when serving as an employee of the hospital during the time the service was provided or when the hospital reports the service as a direct medical education cost on the Medicare and Division cost report.

(2) For requirements for the provision of services, including documentation requirements, follow Medicare guidelines for Teaching Physician Services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03, Renumbered from 410-130-0370
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 6-1994, f. & cert. ef. 2-1-94
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93

Or. Admin. R. 410-130-0230 Administrative Medical Examinations and Reports

(1) This rule does not apply to Managed Health Care plans.

(2) These services are covered only when requested by an CAF, APD, AMH, OYA, Child Welfare branch office or approved by the Division of Medical Assistance Programs (Division). The branch office may request an administrative medical examination or a medical report (DMAP 729) to establish client eligibility for an assistance program or casework planning.

(3) See the Administrative Examination and Report Billing rule for complete billing instructions.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 10-1996, f. 5-31-96, cert. ef. 6-1-96
HR 6-1994, f. & cert. ef. 2-1-94
HR 36-1992, f. & cert. ef. 12-1-92

Or. Admin. R. 410-130-0240 Medical Services

(1) Coverage of medical and surgical services is subject to the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List). Medical and surgical services requiring prior authorization (PA) are listed in Oregon administrative rule (OAR or rule) 410-130-0200, PA Table 130-0200-1, and medical and surgical services that are Not Covered/Bundled services are listed in OAR 410-130-0220, Table 130-0220-1.

(2) Coverage for acupuncture services by an enrolled acupuncture provider are subject to the HERC Prioritized List and the client’s benefit plan.

(3) Coverage for medically appropriate chiropractic services provided by an enrolled chiropractor is subject to the HERC Prioritized List and benefit plan for:

(a) Diagnostic visits including evaluation and management services;

(b) Chiropractic care including manipulative treatment;

(4) Maternity care and delivery:

(a) The Division may consider payment for delivery within a hospital, clinic, birthing center, or home setting;

(b) For out-of-hospital births, the Division may only consider payment for labor and delivery care of women experiencing low risk pregnancy. The Division will determine whether a pregnancy can be considered low risk and an out-of-hospital birth is eligible for payment;

(c) During the Coronavirus (COVID-19) outbreak state of emergency initiated under governor Kate Brown’s executive order 20-03 and any subsequent executive order extending the state of emergency, the division adopts tables 410-130-0240-1, 410-130-0240-2, 410-130-0240-3 and 410-130-0240-4, superseding the requirements in the Prioritized List of Health Services Guideline Note 153 for the purposes described below.

(d) During the Coronavirus (COVID-19) outbreak state of emergency initiated under governor Kate Brown’s executive order 20-03 and any subsequent executive order extending the state of emergency, the division adopts Table 410-130-0240-1 and Table 410-130-0240-3 to outline the absolute risk factors that, if present, would preclude payment for initiation or continuation of any out-of-hospital labor and delivery care. For a planned out-of-hospital birth, the Division requires that a contingency for an in-hospital birth be included in the medical record. The division considers all conditions listed in Tables 410-130-0240-1 and 410-130-0240-3 to necessitate an in-hospital birth if present or anticipated to be present at the onset of labor. The Division may deny payment for labor and delivery services in an out-of-hospital setting if it determines that an in-hospital birth was necessary and appropriate steps to facilitate an in-hospital birth were not pursued. The Division may also deny payment for services if appropriate risk assessments were not performed at initiation of care and throughout pregnancy, or when the appropriate consultation policies described in subsection (e) were not followed. When an in-hospital birth becomes necessary for a client that was seeking a planned out-of-hospital birth and care is transferred from one provider to another, the Division will consider payment for both providers for the portion of care provided. Bill using appropriate CPT and HCPCS codes.

(e) During the Coronavirus (COVID-19) outbreak state of emergency initiated under governor Kate Brown’s executive order 20-03 and any subsequent executive order extending the state of emergency, the division adopts Table 410-130-0240-2 and Table 410-130-0240-4, which contain criteria requiring consultation regarding the management of risk factors during pregnancy and birth for patients receiving out-of-hospital birth care. The division may deny payment if any of the high-risk conditions in tables 410-130-0240-2 or 410-130-0240-4 arise during pregnancy, labor, delivery or the immediate postpartum period and no consultation with an appropriate provider occurs, or if the recommendations of the consulting provider are not adhered to by the out-of-hospital birth attendant in the out-of-hospital setting. For the purposes of consultation under this subsection, an appropriate consulting provider is one of the following:

(A) A provider (MD/DO or CNM) who has active admitting privileges to manage pregnancy in a hospital, or;

(B) An appropriate specialty consultant (e.g., maternal-fetal medicine, hepatologist, hematologist, psychiatrist).

(f) When a provider is practicing within the authorization of his or her license, the division may consider payment for administration of drugs and devices that are used in pregnancy, birth, postpartum care, newborn care, or resuscitation and that are deemed integral to providing safe care.

(g) For out-of-hospital births, drugs authorized in subsection (f) or this section are limited:

(A) For out-of-hospital births, the Division will make no payment for general, spinal, caudal, or epidural anesthesia administered for care associated with labor and delivery;

(B) For out-of-hospital births, the Division will make no payment for inducing, stimulating, or using chemical agents to augment labor during the first or second stages of labor;

(C) For out-of-hospital births, the Division will consider payment for chemical agents administered to inhibit labor only as a temporary measure until referral or transfer of the client to a higher level of care is complete.

(h) Within the home setting, the Division may consider payment for appropriate supplies in addition to delivery payment. The additional payment for supplies includes all supplies, equipment, staff assistance, and newborn screening cards;

(i) During labor in an out-of-hospital setting, should any of the risk factors outlined in Table 410-130-0240-3 develop, the Division requires that the client will be transferred to a hospital, and the Division may deny payment for labor and delivery services if it determines that appropriate steps to facilitate the transfer were not pursued. Appropriate transfer of care must be in accordance with the practitioner’s licensure requirements. When labor management does not result in a delivery, and the client is appropriately transferred to a higher level of care, the provider shall code for labor management only. Bill code 59899 and attach appropriate clinical documentation of services performed with respect to labor management. The Division may also deny payment for services if appropriate risk assessments were not performed during labor, or when the appropriate consultation policies described in subsection (e) were not followed;

(j) For births in an out-of-hospital setting, should any of the risk factors outlined in Table 410-130-0240-3 develop during the postpartum period in the mother, the Division requires that the mother will be transferred to a hospital, and the Division may deny payment for labor and delivery services if it determines that appropriate steps to facilitate the transfer were not pursued. Appropriate transfer of care must be in accordance with the practitioner’s licensure requirements. The Division will consider payment for both providers for the portion of care provided when appropriate. The Division may also deny payment for services if appropriate risk assessments were not performed at initiation of care and throughout pregnancy, or when the appropriate consultation policies described in subsection (e) were not followed;

(k) For multiple vaginal births, use the appropriate CPT code for the first delivery. Use the delivery-only code for the subsequent deliveries. The Division will reimburse the first delivery at 100 percent and the subsequent deliveries at 50 percent of the delivery-only code's maximum allowance. For multiple babies delivered via cesarean section, the Division pays for the cesarean section only once.

(l) The division may deny payment or authorization for planned out-of-hospital birth when conditions arise which in the Division’s judgment create a situation in which a planned out-of-hospital birth is not medically appropriate. For example, having multiple risk conditions requiring consultation may increase the risk sufficiently to indicate the need for transfer of care.

(5) Neonatal Intensive Care Unit (NICU) procedures:

(a) Are reimbursed only to neonatologists and pediatric intensivists for services provided to infants when admitted to a Neonatal or Pediatric Intensive Care Unit (NICU/PICU). All other pediatricians must use other CPT codes when billing for services provided to neonates and infants;

(b) Neonatal intensive care codes are not payable for infants on Extracorporeal Membrane Oxygenation (ECMO). Use appropriate CPT ECMO codes.

(6) Neurology or Neuromuscular payment for polysomnograms and multiple sleep latency tests (MSLT) are each limited to two in a 12-month period.

(7) Oral health services provided by medical practitioners may include an oral assessment and application of topical fluoride varnish during a medical visit for children. Refer to OAR 410-123-1260 Dental Services program rule.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 54-2020, temporary amend filed 09/30/2020, effective 10/01/2020 through 03/29/2021
DMAP 50-2020, amend filed 09/24/2020, effective 09/27/2020
DMAP 17-2020, temporary amend filed 04/01/2020, effective 04/01/2020 through 09/27/2020
DMAP 73-2014, f. 12-9-14, cert. ef. 1-1-15
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 27-2013, f. & cert. ef. 6-25-13
DMAP 58-2012(Temp), f. 12-27-12, cert. ef. 12-28-12 thru 6-25-13
DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 88-2004, f. 11-24-04, cert. ef. 12-1-04
OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 10-1996, f. 5-31-96, cert. ef. 6-1-96
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94, Renumbered from 410-130-0320, 410-130-0340, 410-130-0360 & 410-130-0740
HR 16-1993, f. & cert. ef. 7-2-93
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
HR 36-1992, f. & cert. ef. 12-1-92
HR 18-1992, f. & cert. ef. 7-1-92
HR 8-1992, f. 2-28-92, cert. ef. 3-1-92
HR 2-1992, f. & cert. ef. 1-2-92
HR 24-1991, f. & cert. ef. 6-18-91
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
HR 18-1991(Temp), f. 4-12-91, cert. ef. 4-15-91
HR 14-1991(Temp), f. & cert. ef. 3-7-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0650, 461-014-0690 & 461-014-0700
AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0021 & 461-014-0056
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89
AFS 56-1987, f. 10-29-87, cert. ef. 11-1-87
AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86
AFS 29-1985, f. 5-22-85, cert. ef. 5-29-85
AFS 48-1984(Temp), f. 11-30-84, cert. ef. 12-1-84
AFS 57-1983, f. 11-29-83, cert. ef. 1-1-84
AFS 38-1983, f. & cert. ef. 8-1-83
AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, cert. ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, cert. ef. 6-30-82 for remaining AFS branch offices
AFS 36-1981, f. 6-29-81, cert. ef. 7-1-81
AFS 2-1981, f. 1-9-81, cert. ef. 2-1-81
AFS 56-1980(Temp), f. 8-29-80, cert. ef. 9-1-80
AFS 26-1980, f. 5-21-80, cert. ef. 6-1-80
AFS 31-1978, f. & cert. ef. 8-1-78
AFS 14-1978(Temp), f. 4-14-78, cert. ef. 4-15-78
PWC 868, f. 12-30-77, cert. ef. 2-1-78
PWC 849, f. 7-15-77, cert. ef. 8-1-77
PWC 839(Temp), f. & cert. ef. 4-28-77

Or. Admin. R. 410-130-0255 Immunizations, Vaccines for Children, and Immune Globulins

(1) The Division covers immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Oregon Immunization Program. The approved ACIP recommendations are found in Guideline Note 106 of the Health Evidence Review Commission’s Prioritized List of Health Services as referenced in OAR 410-141-0520, http://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Prioritized-List.aspx.

(2) Providers shall follow the (ACIP) guidelines for immunization schedules. Exceptions include:

(a) On a case-by-case basis, provider may use clinical judgment in accordance with accepted medical practice to provide immunizations on a modified schedule, and;

(b) On a case-by-case basis, provider may modify immunization schedule in compliance with the laws of the State of Oregon, including laws relating to medical and non-medical exemptions for immunizations.

(3) Providers are encouraged to administer combination vaccines when medically appropriate and cost effective.

(4) Providers must use standard billing procedures for adults and for any vaccines that are not part of the Vaccines for Children (VFC) Program.

(5) Vaccines for Children (VFC) is a federal program that provides vaccine serums at no cost to providers for clients ages 0 through 18. All vaccines for this age group and for conditions covered by the VFC program must be obtained through the VFC program. The Division will not reimburse providers for the administration or purchase of privately purchased vaccines if the vaccine could have been obtained through the VFC program. For information about the VFC program or to enroll as a VFC provider, contact the Public Health Immunization Program. The Oregon VFC program website can be located at http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/vfc/Pages/index.aspx

(6) The Division will only reimburse for the administration, not the serum, of vaccines available for free through the VFC Program. Refer to the 12/24/2013 Current Oregon Immunization Program State-Supplied Vaccine Billing Codes table available at http://bit.ly/1c3T6zy for a list of vaccines provided through the VFC Program.

(7) To receive reimbursement for vaccine administration, VFC program providers must bill the Division:

(a) With the appropriate vaccine common procedural terminology (CPT) code included;

(b) Including the appropriate modifier -SL or -26; and

(c) Reporting the vaccine administration in addition to an Evaluation and Management service (e.g., well-child visit) if provided on the same date of service;

(8) For clients with private insurance, providers may bill the Division or the client’s managed care or coordinated care organization (MCO/CCO) directly for the administration of VFC vaccines. Medicaid and CHIP are not considered the “payer of last resort” for administration of VFC vaccines.

(9) In compliance with Section 1202 of the Affordable Care Act ,VFC providers who qualify for the federal primary care rate increase as specified under 42 Code of Federal Regulation (CFR) 447 Subpart G (see also OAR 410-130-0005) are eligible for reimbursement for the administration of VFC vaccines at the Regional Maximum amount:

(a) Effective 1/1/2013 the Regional Maximum amount is $21.96.

(b) For providers that have met the federal primary care definition, MCO and CCOs are required to reimburse the lessor of:

(A) The Regional Maximum administration fee, or

(B) Medicare 2014 RVU and 2009 conversion factor amount.

(c) MCO and CCOs are not required to reimburse the Regional Maximum amount to providers that have not met the federal primary care definition but may at their option.

(d) For all fee for service providers, the Division reimburses the Regional Maximum amount for the administration of VFC vaccines.

(10) The Division covers immune globulins based on the Prioritized List of Health Services. Synagis (palivizumab-rsv-igm) is covered with prior authorization only for high-risk infants and children. Refer to Guideline Note 69 of the Health Evidence Review Commission’s List of Prioritized Services as referenced in OAR 410-141-0520, http://www.oregon.gov/OHA/HPA/CIS-HERC/Pages/Prioritized-List.aspx and Oregon Medicaid Fee-For-Service Prior Authorization Approval Criteria as referenced in 410-121-0040, www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Medical-Surgical.aspx.

[ED. NOTE: Tables referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 50-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 12-2014, f. & cert. ef. 3-13-14
DMAP 49-2013, f. & cert. ef. 9-25-13
DMAP 14-2013(Temp), f. & cert. ef. 3-29-13 thru 9-25-13
DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 15-2010, f. 6-10-10, cert. ef. 7-1-10
DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 45-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03, Renumbered from 410-130-0800
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 51-2002, f. & cert. ef. 10-1-02
OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 4-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97

Or. Admin. R. 410-130-0365 Ambulatory Surgical Center and Birthing Center Services

(1) Ambulatory Surgical Centers (ASC) and Birthing Centers (BC) must be licensed by the Oregon Health Division. ASC and BC services are items and services furnished by an ASC or BC in connection with a covered surgical procedure as specified in the Medical-Surgical Services rule or in the Dental Services rule. Reimbursement is made at all-inclusive global rates based on the surgical procedure codes billed.

(2) If the client has Medicare in addition to Medicaid and Medicare covers a surgery, but not in an ASC setting, then the surgery may not be performed in an ASC.

(3) Global rates include:

(a) Nursing services, services of technical personnel, and other related services;

(b) Any support services provided by personnel employed by the ASC or BC facility;

(d) Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment related to the provision of the surgical procedure(s);

(e) Diagnostic or therapeutic items and services related to the surgical procedure;

(f) Administrative, record-keeping, and housekeeping items and services;

(g) Blood, blood plasma, platelets;

(h) Materials for anesthesia;

(i) Items not separately identified in section (4) of this rule.

(4) Items and services not included in ASC or BC Global Rate:

(a) Practitioner services such as those performed by physicians, licensed physician associate, nurse practitioners, certified registered nurse anesthetists, dentists, podiatrists and Licensed Direct Entry Midwives (for birthing centers only);

(b) The sale, lease, or rental of durable medical equipment to ASC or BC clients for use in their homes;

(d) Ambulance services;

(e) Leg, arm, back and neck brace, or other orthopedic appliances;

(f) Artificial legs, arms, and eyes;

(g) Services furnished by a certified independent laboratory.

(5) ASCs and BCs will not be reimbursed for services that are normally provided in an office setting unless the practitioner has justified the medical appropriateness of using an ASC or BC through documentation submitted with the claim. Practitioner's justification is subject to review by the Division. If payment has been made and the practitioner fails to justify the medical appropriateness for using an ASC or BC facility, the amount paid is subject to recovery by Division.

(6) Procedure coding for non-Birthing Centers:

(a) Bill the same procedure codes billed by the surgeon;

(b) For reduced or discontinued procedures, use Common Procedural Terminology (CPT) instructions and add appropriate modifiers;

(d) For billing instructions regarding multiple procedures, see rule 410-130-0380.

(7) Procedure coding for Birthing Centers:

(a) Bill code 59409 only once for a single vaginal delivery regardless of the total days that the client was in the facility for labor management, delivery and immediate postpartum care;

(b) For delivery of twins:

(A) Bill the delivery of the first twin with 59409; and

(B) Bill the delivery of the second twin with code 59409 on a separate line;

(c) When labor was managed in the BC but a delivery did not result, bill S4005 (Interim labor facility global) and attach a report documenting the circumstances.

(8) Prior authorization is required for all services listed in Table 130-0200-1. Refer to Rule 410-130-0200.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 14-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03, Renumbered from 410-130-0940
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01

Or. Admin. R. 410-130-0368 Anesthesia Services

(1) Anesthesia is not covered for procedures that are below the funding line on the Health Services Commission’s Prioritized List of Health Services (see OAR 410-141-0520).

(2) Effective January 1, 2012 all anesthesia claims submitted must be billed in minutes only. This includes;

(a) Claims for services provided prior to 1/1/12 that are submitted for the first time in 2012;

(b) Resubmitted unpaid claims for services provided prior to 1/1/12; and

(c) Adjustments made to claims for services performed prior to 1/1/12. Units must be converted by the provider from units to minutes.

(3) Qualifier MJ (indicating minutes) must be added to all claims;

(a) Claims with qualifier UN (indicating units) will be denied; and

(b) Claims without a qualifier will be denied.

(4) Reimbursement is based on the base units assigned to each anesthesia code listed in the current American Society of Anesthesiology Relative Value Guide plus one unit per each 15 minutes of anesthesia time, except for anesthesia for neuraxial labor analgesia/anesthesia/anesthesia (code 01967). See (5) below for reimbursement of neuraxial labor analgesia/anesthesia.

(a) The Division of Medical Assistance Programs (Division) will automatically calculate payment by adding the base units of the billed anesthesia code plus a unit per each 15 minutes of anesthesia time;

(b) Reimbursement will be made at a fraction of a unit for the last 1-14 minutes of anesthesia time;

(5) Anesthesia for neuraxial labor analgesia/anesthesia (code 01967) will be paid at a flat rate regardless of the units billed.

(6) Reimbursement for qualifying circumstances codes 99100-99140 and modifiers P1-P6 is bundled in the payment for codes 00100-01999. Do not add charges for 99100-99140 and modifiers P1-P6 in charges for 00100-01999.

(7) A valid consent form is required for all hysterectomies and sterilizations.

(8) If prior authorization (PA) was not obtained for a procedure that requires PA, then the anesthesia services may not be paid. Refer to OAR 410-130-0200 PA Table 130-0200-1.

(9) Anesthesia services are not payable to the provider performing the surgical procedure except for moderate (conscious) sedation.

(10) Moderate (conscious) sedation must be billed with codes 99143-99150.

[ED. NOTE: Tables referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05

Or. Admin. R. 410-130-0380 Surgery Guidelines

(1) The Division of Medical Assistance Programs (Division) reimburses all covered surgical procedures as global packages. Global payments do not include initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.

(2) Surgical procedures listed in the Medical-Surgical Services administrative rules with prior authorization (PA) indicated require authorization unless they are emergent.

(3) Global payment for major surgery includes:

(a) Surgery;

(b) Pre-operative visits within 15 days of the surgery (except the initial consultation);

(d) Related follow-up visits within 90 days after the surgery;

(e) Treatment of complications not requiring a return trip to the operating room;

(f) Hospital discharge.

(4) Global payment for minor surgery includes:

(a) Surgery;

(b) Pre-operative visits within 15 days of the surgery;

(d) Related follow-up visits for 10 days after the surgery;

(e) Hospital discharge.

(5) Global payment for endoscopy includes:

(a) Surgery;

(b) Related visit on the same day as the endoscopy procedure;

(d) Pre-operative and post-operative care provided by the surgeon’s associate(s) or by another physician “on call” for the surgeon are considered included in the reimbursement to the surgeon and will not be paid in addition to the payment to the surgeon;

(e) Do not bill separately for procedures which are considered to be bundled in another procedure. Payment for bundled services is included in the primary surgery payment.

(6) Co-surgeons — Two or more surgeons/same or different specialties/separate functions/one major or complex surgery:

(a) Add modifier -62 to procedure code(s);

(b) Payment will be determined by medical review.

(7) Team Surgeons — Two or more surgeons/different specialties performing/separate surgeries/same operative session:

(a) Add modifier -66 to procedure code(s);

(b) Payment will be determined by medical review.

(8) Multiple Surgical Procedures performed during the same operative session:

(a) Primary Procedure paid at 100% of the Division maximum fee for that procedure;

(b) Second and third procedure paid at 50% of the Division maximum fee;

(d) Endoscopic procedures paid at 100% of the Division maximum fee for the primary level procedure. The Division fee for insertion will be deducted from the maximum allowable for each additional procedure performed at the same site;

(e) Bill each procedure on separate lines (even multiples of the same procedure) unless the code description specifies “each additional”;

(f) Bilateral procedures must be billed on two lines unless a single code identifies a bilateral procedure. Use modifier -50 only on the second line;

(g) Reimbursement for laparotomy is included in the surgical procedure and should not be billed separately or in addition to the surgical procedure;

(h) For Integumentary System codes 10000 thru 17999, bill multiples of the same procedure on the same line with the appropriate quantity unless the code indicates the first in a series (i.e., code 11100) or the code is for multiple procedures (i.e., code 11900).

(9) Surgical Assistance — Payment is restricted to physicians, naturopaths, podiatrists, dentists, nurse practitioners, licensed physician associate, and registered nurse first assistants:

(a) The assistance must be medically appropriate;

(b) No payment will be made for surgical assistant for minor surgical or diagnostic procedures, e.g., “scoping” procedures;

(d) Use an appropriate modifier to indicate assistance.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 15-2025, minor correction filed 01/09/2025, effective 01/09/2025
OMAP 51-2002, f. & cert. ef. 10-1-02
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
HR 23-1992, f. 7-31-92, cert. ef. 8-1-92
HR 8-1992, f. 2-28-92, cert. ef. 3-1-92
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0710
AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0048, 461-014-0049, 461-014-0053, 461-014-0055 & 461-014-0056
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 56-1987, f. 10-29-87, cert. ef. 11-1-87
AFS 30-1987, f. 7-15-87, cert. ef. 8-1-87
AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86
AFS 38-1986, f. 4-29-86, cert. ef. 6-1-86
AFS 29-1985, f. 5-22-85, cert. ef. 5-29-85
AFS 48-1984(Temp), f. 11-30-84, cert. ef. 12-1-1984
AFS 30-1984, f. 7-26-84, cert. ef. 8-1-84
AFS 4-1984, f. & cert. ef. 2-1-84
AFS 57-1983, f. 11-29-83, cert. ef. 1-1-84
AFS 2-1983, f. & cert. ef. 1-31-83
AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, cert. ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, cert. ef. 6-30-82 for remaining AFS branch offices
AFS 26-1980, f. 5-21-80, cert. ef. 6-1-80
AFS 32-1978, f. & cert. ef. 8-1-78
PWC 868, f. 12-30-77, cert. ef. 2-1-78

Or. Admin. R. 410-130-0562 Abortion

For medically induced abortions by oral ingestion of medication use S0199 for all visits, counseling, lab tests, ultrasounds, and supplies. S0199 is a global package except for medication:

(1) Bill medications with codes S0190-S0191 and appropriate HCPCS codes.

(2) For surgical abortions use CPT codes 59840 through 59857:

(3) For services related to surgical abortion such as lab, ultrasound and pathology bill separately. Add modifier U4 (a Division of Medical Assistance Programs (Division) modifier) for surgical abortion related services.

(4) Use the most appropriate ICD-10 diagnosis code.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 10-1996, f. 5-31-96, cert. ef. 6-1-96
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 23-1992, f. 7-31-92, cert. ef. 8-1-92
HR 8-1992, f. 2-28-92, cert. ef. 3-1-92
HR 43-1991, f. & cert. ef. 10-1-91
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91

Or. Admin. R. 410-130-0580 Hysterectomies and Sterilization

Refer to OAR 410-130-0200 Prior Authorization, Table 130-0200-1 and 410-130-0220 Not Covered/Bundled Services, Table 130-0220-1.

(1) Hysterectomies:

(a) Hysterectomies performed for the sole purpose of sterilization are not covered.

(b) All hysterectomies, except radical hysterectomies, require prior authorization (PA).

(c) A properly completed Hysterectomy Consent form (DMAP 741) or a statement signed by the performing physician, depending upon the following circumstances, is required for all hysterectomies:

(A) When a person is capable of bearing children:

(i) Prior to the surgery, the person securing authorization to perform the hysterectomy must inform the patient and their representative, if any, orally and in writing, that the hysterectomy will render them permanently incapable of reproducing;

(ii) The patient or their representative, if any, must sign the consent form to acknowledge they received that information.

(B) When a person is sterile prior to the hysterectomy, the physician who performs the hysterectomy must certify in writing that the patient was already sterile prior to the hysterectomy and state the cause of the sterility;

(C) When there is a life-threatening emergency situation that requires a hysterectomy in which the physician determines that prior acknowledgment is not possible, the physician performing the hysterectomy must certify in writing that the hysterectomy was performed under a life-threatening emergency situation in which they determined prior acknowledgment was not possible and describe the nature of the emergency.

(d) In cases of retroactive eligibility, the physician who performs the hysterectomy must certify in writing one of the following:

(A) The patient was informed before the operation that the hysterectomy would make them permanently incapable of reproducing;

(B) The patient was previously sterile and states the cause of the sterility; or

(C) The hysterectomy was performed because of a life-threatening emergency situation in which prior acknowledgment was not possible and describes the nature of the emergency.

(e) Do not use the Consent to Sterilization form (DMAP 742B ) for hysterectomies.

(f) Submit a copy of the Hysterectomy consent form with the claim.

(2) Sterilization:

(a) Sterilization consent forms:

(A) The patient needs a copy of a properly completed Consent to Sterilization form (DMAP 742 B or HHS-687);

(B) The original consent form must be retained by the provider for clinical records;

(D) Prior authorization is not required.

(b) Voluntary Sterilization:

(A) Consent for sterilization must be an informed choice. The consent is not valid if signed when the member is:

(i) In labor; or

(ii) Under the influence of alcohol or drugs.

(B) Ages 15 years or older who are mentally competent to give informed consent:

(i) At least 30 days, but not more than 180 days, must have passed between the date of the informed written consent (date of signature) and the date of the sterilization except:

(I) In the case of premature delivery by vaginal or cesarean section the consent form must have been signed at least 72 hours before the sterilization is performed and more than 30 days before the expected date of confinement;

(II) In cases of emergency abdominal surgery (other than cesarean section), the consent form must have been signed at least 72 hours before the sterilization was performed.

(ii) The member must sign and date the consent form before it is signed and dated by the person obtaining the consent. The date of signature must meet the above criteria. The person obtaining the consent must sign the consent form any time after the member has signed but before the sterilization is performed. If an interpreter is provided to assist the individual being sterilized, the interpreter must also sign the consent form on the same date as the member;

(iii) The member must be legally competent to give informed consent. The physician performing the procedure, and the person obtaining the consent, if other than the physician, must review with the member the detailed information appearing on the Consent to Sterilization form regarding effects and permanence of the procedure, alternative birth control methods, and explain that withdrawal of consent at any time prior to the surgery will not result in any loss of other program benefits.

(c) Involuntary sterilization of people who lack the ability to give informed consent and are 18 years of age or older must meet the following:

(A) Only the Circuit Court of the county in which the member resides can determine that the member is unable to give informed consent;

(B) The Circuit Court must determine that the member requires sterilization;

(C) When the court orders sterilization, it issues a Sterilization Order. The order must be attached to the billing invoice. No waiting period or additional documentation is required.

(d) Submit the Consent to Sterilization Form (DMAP 742 B or HHS-687) along with the claim. The Consent to Sterilization form must be completed in full:

(A) Consent forms submitted to the Division without signatures and/or dates of signature by the member or the person obtaining consent are invalid;

(B) The member and the person obtaining consent may not sign or date the consent retroactively;

(C) The performing physician must sign the consent form. The date of signature must be either the date the sterilization was performed or a date following the sterilization.

[ED. NOTE: Forms referenced are available from the agency.]

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 37-2026, amend filed 09/09/2026, effective 09/09/2026
DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 12-2008, f. 4-29-08, cert. ef. 5-1-08
DMAP 27-2007(Temp), f. & cert. ef. 12-20-07 thru 5-15-08
DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
HR 6-1994, f. & cert. ef. 2-1-94
HR 23-1992, f. 7-31-92, cert. ef. 8-1-92
HR 43-1991, f. & cert. ef. 10-1-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0840
AFS 48-1989, f. & cert. ef. 8-24-89
Renumbered from 461-014-0030, AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86
AFS 42-1985, f. & cert. ef. 7-1-85
AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, cert. ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices
AFS 79-1981, f. 11-24-81, cert. ef. 12-1-81
AFS 50-1981(Temp), f. & cert. ef. 8-5-81
AFS 11-1979, f. 6-18-79, cert. ef. 7-1-79
AFS 4-1979(Temp), f. & cert. ef. 3-8-79
PWC 868, f. 12-30-77, cert. ef. 2-1-78
PWC 834, f. 3-31-77, cert. ef. 5-1-77
PWC 813, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76

Or. Admin. R. 410-130-0585 Family Planning Services

(1) Family planning services are those intended to prevent or delay pregnancy, or otherwise control family size.

(2) The Division of Medical Assistance Programs (Division) covers family planning services for clients of childbearing age (including minors who are considered to be sexually active).

(3) Family Planning services include:

(a) Annual exams;

(b) Contraceptive education and counseling to address reproductive health issues;

(d) Radiology services;

(e) Medical and surgical procedures, including tubal ligations and vasectomies;

(f) Pharmaceutical supplies and devices.

(4) Clients may seek family planning services from any provider enrolled with the Division, even if the client is enrolled in a Prepaid Health Plan (PHP). Reimbursement for family planning services is made either by the client’s PHP or the Division. If the provider is:

(a) A participating provider with the client’s PHP, bill the PHP;

(b) An enrolled Division provider, but is not a participating provider with the client’s PHP, bill the Division and add modifier –FP to the billed code.

(5) Family planning methods include natural family planning, abstinence, intrauterine device, cervical cap, prescriptions, sub-dermal implants, condoms, and diaphragms.

(6) Bill all family planning services with the most appropriate ICD-10-CM diagnosis code the most appropriate CPT or HCPCS code and add modifier –FP.

(7) For annual family planning visits use the appropriate CPT code in the Preventative Medicine series (9938X-9939X) and add modifier -FP. These codes include comprehensive contraceptive counseling.

(8) When comprehensive contraceptive counseling is the only service provided at the encounter, use a CPT code from the Preventative Medicine, Individual Counseling series (99401-99404) and add modifier -FP.

(9) Bill contraceptive supplies with the most appropriate HCPCS codes.

(10) Where there are no specific CPT or HCPCS codes, use an appropriate unlisted code and add modifier -FP. Bill supplies at acquisition cost.

[ED. NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.152
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 45-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 51-2002, f. & cert. ef. 10-1-02
OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02
OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 10-1996, f. 5-31-96, cert. ef. 6-1-96
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
HR 8-1992, f. 2-28-92, cert. ef. 3-1-92
HR 43-1991, f. & cert. ef. 10-1-91
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91

Or. Admin. R. 410-130-0587 Family Planning Clinic Services

(1) This rule pertains only to Family Planning Clinics.

(2) To enroll with the Division of Medical Assistance Programs (Division) as a family planning clinic, a provider must also be enrolled with the Office of Family Health as an Oregon Contraceptive Care (CCare) provider.

(3) Family planning clinics must follow all applicable CCare and the Division rules.

(4) The Division will reimburse family planning clinics an encounter rate only when the primary purpose of the visit is for family planning.

(5) Bill HCPCS code T1015 “Clinic visit/encounter, all-inclusive; family planning” for all encounters where the primary purpose of the visit is contraceptive in nature:

(a) This encounter code includes the visit and any procedure or service performed during that visit including:

(A) Annual family planning exams;

(B) Family planning counseling;

(D) Diaphragm fittings;

(E) Dispensing of contraceptive supplies and contraceptive medications;

(F) Contraceptive injections.

(b) Do not bill procedures, such as IUD insertions, diaphragm fittings or injections, with CPT or HCPCS codes;

(d) Reimbursement for educational materials is included in T1015. Educational materials are not billable separately.

(6) Reimbursement for T1015 does not include payment for family planning (FP) supplies and medications:

(a) Bill contraceptive supplies and contraceptive medications separately using HCPCS codes. Where there are no specific HCPCS codes, use an appropriate unspecified HCPCS code:

(A) Bill spermicide code A4269 per tube;

(B) Bill contraceptive pills code S4993 per monthly packet;

(b) Bill all contraceptive supplies and contraceptive medications at acquisition cost;

(d) Non-contraceptive medications are not billable under this program.

(7) Reimbursement for T1015 does not include payment for laboratory tests:

(a) Clinics and providers who perform lab tests in their clinics and are CLIA certified to perform those tests may bill CPT and HCPCS lab codes in addition to T1015;

(b) Add modifier -FP after lab codes to indicate that the lab was performed during an FP encounter;

(8) Encounters where the primary purpose of the visit is not contraceptive in nature, use appropriate CPT codes and do not add modifier -FP.

(9) When billing providers who are not participants in a Prepaid Health Plan (PHP) for services provided to clients enrolled in a PHP, add modifier -FP to the billed code.

[ED. NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.152
DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 45-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 78-2003, f. & cert. ef. 10-1-03

Or. Admin. R. 410-130-0595 Maternity Case Management

(1) The primary purpose of the Maternity Case Management (MCM) program is to optimize pregnancy outcomes, including reducing the incidence of low birth weight babies. MCM services are tailored to the individual client needs. These services are provided face-to-face throughout the client’s pregnancy, unless specifically indicated in this rule.

(2) This program:

(a) Is available to all pregnant clients receiving Medical Assistance Program coverage;

(b) Expands perinatal services to include management of health, economic, social and nutritional factors through the end of pregnancy and a two-month postpartum period;

(d) Is an additional set of services over and above medical management of pregnant clients;

(e) Allows billing of intensive nutritional counseling services.

(3) Any time there is a significant change in the health, economic, social, or nutritional factors of the client, the prenatal care provider must be notified.

(4) Only one provider at a time may provide MCM services to the client. The provider must coordinate care to ensure that duplicate claims for MCM services are not submitted to the Division.

(5) Definitions:

(a) Case Management — An ongoing process to assist and support an individual pregnant client in accessing necessary health, social, economic, nutritional, and other services to meet the goals defined in the Client Service Plan (CSP)(defined below);

(b) Case Management Visit — A face-to-face encounter between a Maternity Case Manager and the client that must include two or more specific training and education topics, address the CSP and provide an on-going relationship development between the client and the visiting provider.

(c) Client Service Plan (CSP) — A written systematic, client coordinated plan of care which lists goals and actions required to meet the needs of the client as identified in the Initial Assessment (defined below) and includes a client discharge plan/summary;

(d) High Risk Case Management — Intensive level of services provided to a client identified and documented by the Maternity Case Manager or prenatal care provider as being high risk;

(e) High Risk Client — A client who has a current (within the last year) documented alcohol, tobacco or other drug (ATOD) abuse history, or who is 17 or under, or has other conditions identified by the case manager anytime during the course of service delivery;

(f) Home/Environmental Assessment — A visit to the client's primary place of residence to assess the health and safety of the client's living conditions;

(g) Initial Assessment — Documented, systematic collection of data with planned interventions as outlined in a CSP to determine current status and identify needs and strengths in physical, psychosocial, behavioral, developmental, educational, mobility, environmental, nutritional, and emotional areas;

(h) Nutritional Counseling — Intensive nutritional counseling for clients who have at least one of the conditions listed under Nutritional Counseling (12)(a)(A-I) in this rule;

(i) Prenatal/Perinatal care provider — The physician, licensed physician associate, nurse practitioner, certified nurse midwife, or licensed direct entry midwife providing prenatal or perinatal (including labor and delivery) and/or postnatal services to the client;

(j) Case Management Visit Outside the Home — An encounter outside the client’s home between a Maternity Case Manager and the client where identical services of a Case Management Home Visit (G9012) are provided.

(6) Maternity case manager qualifications:

(a) Maternity case managers must be currently licensed as a:

(A) Physician;

(B) Physician associate;

(D) Certified nurse midwife;

(E) Direct entry midwife;

(F) Social worker; or

(G) Registered nurse;

(b) The maternity case manager must be a Division enrolled provider or deliver services under an appropriate Division enrolled provider. See provider qualifications in the Division’s General Rule 410-120-1260.

(d) Other paraprofessionals may provide specific services with the exclusion of the Initial Assessment (G9001) while working under the supervision of one of the practitioners listed above in this section;

(e) The maternity case manager must sign off on all services delivered by a paraprofessional;

(f) Specific services not within the recognized scope of practice of the provider of MCM services must be referred to an appropriate discipline.

(7) Nutritional counselor qualifications — nutritional counselors must be:

(a) A licensed dietician (LD) licensed by the Oregon Board of Examiners of Licensed Dieticians; and

(b) A registered dietician (RD) credentialed by the Commission on Dietetic Registration of the American Dietetic Association (ADA).

(8) Documentation requirements:

(a) Documentation is required for all MCM services in accordance with Division General Rule 410-120-1360; and

(b) A correctly completed Division form 2470, 2471, 2472 and 2473 or their equivalents meet minimum documentation requirements for MCM services.

(9) G9001 — Initial Assessment must be performed by a licensed maternity case manager as defined under (6)(a)(A-G) in this rule:

(a) Services include:

(A) Client assessment as outlined in the "Definitions" section of this rule;

(B) Development of a CSP that addresses identified needs;

(i) A prenatal care provider;

(ii) A dental health provider;

(D) Forwarding the Initial Assessment and the CSP to the prenatal care provider;

(E) Communicating pertinent information to the prenatal care provider and others participating in the client's medical and social care;

(b) Data sources relied upon may include:

(A) Initial Assessment;

(B) Client interviews;

(D) Contacts with collateral providers;

(E) Other professionals; and

(F) Other parties on behalf of the client;

(d) The Initial Assessment (G9001) is billable once per pregnancy per provider and must be performed before providing any other MCM services. Only a Home/Environmental Assessment (G9006) and a Case Management Home Visit (G9012) or Case Management Visit Outside the Home (G9011) may be performed and billed on the same day as an Initial Assessment.

(10) G9002 — Case Management includes:

(a) Face-to-face client contacts;

(b) Implementation and monitoring of a CSP:

(A) The client's records must include a CSP and written updates to the plan;

(B) The CSP includes determining the client's strengths and needs, setting specific goals and utilizing appropriate resources in a cooperative effort between the client and the maternity case manager;

(A) Contact with Department of Human Services (Department) case worker, if assigned;

(B) Maintain contact with prenatal care provider to ensure service delivery, share information, and assist with coordination;

(d) Linkage to client services indicated in the CSP:

(A) Make linkages, provide information and assist the client in self-referral;

(B) Provide linkage to labor and delivery services;

(e) Ongoing nutritional evaluation with basic counseling and referrals to nutritional counseling, as indicated;

(f) Utilization and documentation of the “5 A’s” brief intervention protocol for addressing tobacco use (US Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence, 2008). Routinely:

(A) Ask all clients about smoking status;

(B) Advise all smoking clients to quit;

(D) Assist all those wanting to quit by referring them to the Quitline and/or other appropriate tobacco cessation counseling and provide motivational information for those not ready to quit;

(E) Arrange follow-up for interventions;

(g) Provide training and education on all mandatory topics - Refer to Table 130-0595-2 in this rule;

(h) Provide client advocacy as necessary to facilitate access to benefits or services;

(i) Assist client in achieving the goals in the CSP;

(j) G9002 is billable when three months or more of services were provided. Services must be initiated during the prenatal period and carried through the date of delivery;

(k) G9002 is billable once per pregnancy.

(11) G9005 — High Risk Case Management:

(a) Enhanced level of services that are more intensive and are provided in addition to G9002;

(b) A client can be identified as high risk at any time when case management services are provided, therefore G9005 can be billed after 3 months of case management services.

(d) G9002 can not be billed in addition to G9005.

(12) S9470 — Nutritional counseling:

(a) Is available for clients who have at least one of the following conditions:

(A) Chronic disease such as diabetes or renal disease;

(B) Hematocrit (Hct) less than 34 or hemoglobin (Hb) less than 11 during the first trimester, or Hct less than 32 or Hb less than 10 during the second or third trimester;

(D) Pregnancy weight gain outside the appropriate Women, Infants and Children (WIC) guidelines;

(E) Eating disorder;

(F) Gestational diabetes;

(G) Hyperemesis;

(H) Pregnancy induced hypertension (pre-eclampsia); or

(I) Other identified conditions;

(b) Documentation must include all of the following:

(A) Nutritional assessment;

(B) Nutritional care plan;

(d) S9470 is billable only once per pregnancy.

(13) G9006 — Home/Environmental Assessment:

(a) Includes an assessment of the health and safety of the client's living conditions with training and education of all topics as indicated in Table 130-0595-1 in this rule;

(b) G9006 may be billed only once per pregnancy, except an additional Home/Environmental Assessments may be billed with documentation of problems which necessitate follow-up assessments or when a client moves. Documentation must be submitted with the claim to support the additional Home/Environment Assessment.

(14) G9011 — Case Management Visit Outside the Home:

(a) A face-to-face encounter between a maternity case manager and the client in a place other than the home which meets all requirements of a Case Management Home Visit (G9012) or a telephone encounter when a face-to-face Case Management Visit is not possible or practical;

(b) G9011 is billable in lieu of a Case Management Home Visit and counted towards the total number of Case Management Home Visits (see G9012 for limitations).

(15) G9012 – Case Management Home Visit:

(a) Each Case Management Home Visit must be performed in the client’s home and must include:

(A) An evaluation and/or revision of objectives and activities addressed in the CSP: and

(B) At least two training and education topics listed in Table 130-0595-2 in this rule;

(b) Four Case Management Home Visits (G9012) may be billed per pregnancy. Case Management Visits Outside the Home (G9011) are included in this limitation;

(c) Six additional Case Management Home Visits may be billed if the client is identified as high risk and services were provided for three months or longer;

(d) These additional six visits may only be billed with or after High Risk Case Management (G9005) has been billed. Case Management Visits Outside the Home (G9011) are included in this limitation.

(16) Table 130-0595-1

(17) Table 130-0595-2

[ED. NOTE: Tables & Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 16-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12
DMAP 24-2010, f. & cert. ef. 9-1-10
DMAP 8-2010(Temp), f. 4-13-10, cert. ef. 4-15-10 thru 10-1-10
DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03, Renumbered from 410-130-0100
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 51-2002, f. & cert. ef. 10-1-02
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 34-1998, f. & cert. ef. 10-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 43-1991, f. & cert. ef. 10-1-91
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0580
AFS 71-1989, f. & cert. ef. 12-1-89
AFS 54-1989(Temp), f. 9-28-89, cert. ef. 10-1-89
AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0200 & 461-014-0201
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 57-1987, f. 10-29-87, cert. ef. 11-1-87

Or. Admin. R. 410-130-0605 Newborn Nurse Home Visiting Services

(1) Definitions.

(a) “Comprehensive newborn nurse home visit” has the meaning described in OAR 333-006-0010 a 333-006-0120;

(b) “HSD” means the Oregon Health Authority’s Health Systems Division;

(d) “Eligible Client” means an individual who is found eligible for Medicaid or the Children’s Health Insurance Program (CHIP) by the Oregon Health Authority (Authority) at the time the services are furnished;

(e) “Oregon Health Plan (OHP)” means the Medicaid program in Oregon that is known as the OHP and governed by a series of laws passed by the Oregon Legislature with the intention of providing universal access to healthcare to Oregonians. OHP is also governed by many federal laws;

(f) “Newborn Nurse Home Visiting Program (NNHV)” has the meaning described in OAR 333-006-0010. The program provides services to Medicaid-eligible newborns and their families. The program is governed by Public Health, Division 6, OAR 333-006-0000 to 333-006-333-006-0160. “Newborn Nurse Home Visiting Program” and “Universally Offered Newborn Nurse Home Visiting Program” are synonymous and may be used interchangeably;

(g) “Newborn nurse home visits” means home visits provided under the Newborn Nurse Home Visiting Program.

(2) Purpose. The primary purpose of providing Newborn Nurse Home Visiting services is to support healthy child development and strengthen families. Newborn nurse home visits are a component of the services provided to families with newborns as part of the Newborn Nurse Home Visiting Program.

(3) Governing Rules. This rule is to be used in conjunction with Newborn Nurse Home Visiting Program (NNHV) Rules 333-006-0000 to 333-006-333-006-0160, Targeted Case Management (TCM) rules OAR 410-138-0000 through 410-138-0390, OAR 410-130-0605, and the HSD’s General Rules chapter 410, Division 120.

(4) Eligibility Requirements. The services may be provided to Medicaid eligible infants 0 through 6 months of age. Members must be an eligible client enrolled in OHP on the date of service. NNHV is a carveout from the CCO benefit.

(5) Providers Requirements. Newborn Nurse Home Visiting providers must be enrolled with HSD on the date of service. To be enrolled a provider a must be certified by the Authority according to OAR 333-006-0070.

(6) A comprehensive newborn nurse home visit:

(a) Must meet the requirements described in OAR 333-006-0120. Medical services provided include a comprehensive caregiver (if applicable) and newborn physical nursing assessment as well as standardized anticipatory and supportive guidance;

(b) May include an assessment of family strengths, risks, and needs and referrals for identified interventions or community resources are provided in coordination with the targeted case management requirements described in OAR 410-138-0000 through 410-138-0390;

(c) For Newborn Nurse home visiting services for births with multiples (twins, triplets, etc.) additional newborns may be reimbursed at a reduced case rate;

(d) Is a requirement for OAR 410-130-0605(7).

(7) the Authority will reimburse newborn nurse home visits using a bundled case rate. To be eligible for reimbursement newborn nurse home visits:

(a) Must include at a minimum a comprehensive newborn nurse home visit meeting the requirements of OAR 333-006-0120 and 410-130-0605(6);

(b) May include up to two follow up support visits.

(8) Reimbursement may be made for one (1) support visit prior to the comprehensive visit:

(a) This pre-comprehensive visit may be provided if the nurse home visitor determines the family has immediate postpartum needs within two weeks of birth;

(b) A pre-comprehensive visit may be billed separately from the case rate if meeting the requirements of a support home visit described in OAR 333-006-0120.

(9) The provision of services shall be documented in the client's medical record by the Home visitor who provides home visits under the Newborn Nurse Home Visiting Program. The client’s record shall include the dates of service, and a description of services provided.

(10) Requests for reimbursement for home visits under the Newborn Nurse Home Visiting Program shall:

(a) Use CPT 99502 with modifier 32 for one time for a comprehensive visit case rate. This service may be provided over 1-3 home visits;

(b) Use CPT 99502 with modifier TT for one time for a comprehensive visit case rate for each additional baby for births with multiples (twins, triplets, etc.);

(d) Claim only one comprehensive visit case rate per newborn;

(e) Claim only one pre-comprehensive visit per delivery.

(11) Only an enrolled provider under the Newborn Nurse Home Visiting Program, provider type 64/519, may be the billing provider for home visits under the Newborn Nurse Home Visiting Program.

(12) Newborn Nurse Home Visiting rates are based on the current published fee schedule.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 58-2022, adopt filed 06/21/2022, effective 06/22/2022
DMAP 55-2021, temporary adopt filed 12/29/2021, effective 01/01/2022 through 06/25/2022

Or. Admin. R. 410-130-0670 Death With Dignity

(1) All Death with Dignity services must be billed directly to the Division of Medical Assistance Programs (Division), even if the client is in a managed care plan.

(2) Death with Dignity is a covered service, incorporated in the "comfort care" condition/treatment line on the Health Services Commission's Prioritized List of Health Services.

(3) The following physician visits and medical encounters are billable when performed by a licensed physician or psychologist:

(a) The medical confirmation of the terminal condition;

(b) The two visits in which the client makes the oral request;

(d) The visit in which the prescription is written;

(e) Counseling consultation(s); and

(f) Medication and dispensing.

(4) More than one of the services listed in sections (3)(a) through (3)(f) may be provided during the same visit. Additional visits for discussion or counseling are also covered for payment.

(5) Billing:

(a) All claims for Death with Dignity services must be made on a paper CMS-1500 billing form;

(b) Do not submit a claim for Death with Dignity services electronically or on an 837P;

(d) The Division unique diagnosis code PAD-00 must be entered in Field 21 of the CMS-1500 billing form. Do not list any additional diagnosis codes in this field;

(e) Claims must be submitted only on paper to: 500 Summer Street NE E44, Salem, OR 97308;

(f) Prescriptions must be billed only with the Division unique code 8888-PAID-00. This code must be entered in Field 24D of the CMS-1500. In addition, the actual NDC number of the drug dispensed and the dosage must be listed below the prescription code;

(g) the Division may be billed for prescription services only when the pharmacy has been properly notified by the physician in accordance with OAR 847-015-0035. This OAR requires the physician to have the client's written consent to contact and inform the pharmacist of the purpose of the prescription.

[ED. NOTE: Forms referenced available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 9-2026, minor correction filed 03/23/2026, effective 03/23/2026
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 2-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 46-1998, f. & cert. ef.12-1-98

Or. Admin. R. 410-130-0680 Laboratory and Radiology

(1) The following tables list the medical and surgical services that:

(a) Require prior authorization (PA) — OAR 410-130-0200 Table 130-0200-1 (PET scans require PA and are included in the table), and;

(b) Are not covered/bundled — OAR 410-130-0220 Table 130-0220-1.

(2) Newborn screening (NBS) kits and collection and handling for newborn screening (NBS) tests performed by the Oregon State Public Health Laboratory (OSPHL) are considered bundled into the delivery fee and, therefore, must not be billed separately. Replacement of lost NBS kits may be billed with code S3620 with modifier –TC. The loss must be documented in the client's medical record. NBS confirmation tests performed by reference laboratories at the request of the OSPHL will be reimbursed only to the OSPHL.

(3) The Division of Medical Assistance Programs (Division) covers lab tests performed in relation to a transplant only if the transplant is covered and if the transplant has been authorized. See the Division Transplant Services administrative rules (chapter 410, division 124).

(4) All lab tests must be specifically ordered by, or at the direction of a licensed medical practitioner within the scope of their license.

(5) If a lab sends a specimen to a reference lab for additional testing, the reference lab may not bill for the same tests performed by the referring lab.

(6) When billing for lab tests, use the date that the specimen was collected as the date of service (DOS) even if the tests were not performed on that date.

(7) Reimbursement for drawing/collecting or handling samples:

(a) The Division will reimburse providers once per day regardless of the frequency performed for drawing/collecting the following samples:

(A) Blood — by venipuncture or capillary puncture, and;

(B) Urine — only by catheterization.

(b) The Division will not reimburse for the collection and/or handling of other specimens, such as PAP or other smears, voided urine samples, or stool specimens. Reimbursement is bundled in the reimbursement for the exam and/or lab procedures and is not payable in addition to the laboratory test.

(8) Pass-along charges from the performing laboratory to another laboratory, medical practitioner, or specialized clinic are not covered for payment and are not to be billed to the Division.

(9) Only the provider who performs the test(s) may bill the Division.

(10) Clinical Laboratory Improvement Amendments (CLIA) Certification:

(a) The Division will only reimburse laboratory services to providers who are CLIA certified by the Centers for Medicare and Medicaid Services (CMS);

(b) CLIA requires all entities that perform even one test, including waived tests on... "materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings" to meet certain Federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory;

(d) Payment is limited to the level of testing authorized by the CLIA certificate at the time the test is performed.

(11) Organ Panels:

(a) The Division will only reimburse panels as defined by the CPT codes for the year the laboratory service was provided. Tests within a panel may not be billed individually even when ordered separately. The same panel may be billed only once per day per client;

(b) The Division will pay at the panel maximum allowable rate if two or more tests within the panel are billed separately and the total reimbursement rate of the combined codes exceeds the panel rate, even if all the tests listed in the panel are not ordered or performed.

(12) Radiology:

(a) Provision of diagnostic and therapeutic radionuclide(s), HCPCS A9500-A9699, are payable only when given in conjunction with radiation oncology and nuclear medicine codes 77401-79999;

(b) HCPCS codes R0070 through R0076 are covered.

(13) Reimbursement of contrast and diagnostic-imaging agents is bundled in the radiology procedure except for low osmolar contrast materials (LOCM).

(14) Supply of LOCM may be billed in addition to the radiology procedure only when the following criteria are met:

(a) Prior adverse reaction to contrast material, with the exception of a sensation of heat, flushing or a single episode of nausea or vomiting;

(b) History of asthma or significant allergies;

(c) Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction or pulmonary hypertension;

(d) Decrease in renal function;

(e) Diabetes;

(f) Dysproteinemia;

(g) Severe dehydration;

(h) Altered blood brain barrier (i.e., brain tumor, subarachnoid hemorrhage);

(i) Sickle cell disease, or;

(j) Generalized severe debilitation.

(15) X-ray and EKG interpretations in the emergency room:

(a) The Division reimburses only for one interpretation of an emergency room patient’s x-ray or EKG. The interpretation and report must have directly contributed to the diagnosis and treatment of the patient;

(b) The Division considers a second interpretation of an x-ray or EKG to be for quality control purposes only and will not be reimbursed;

(c) Payment may be made for a second interpretation only under unusual circumstances, such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed.

[ED. NOTE: Tables referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 50-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 51-2002, f. & cert. ef. 10-1-02
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 15-1998, f. & cert. ef. 5-1-98
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 10-1996, f. 5-31-96, cert. ef. 6-1-96
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
HR 33-1992, f. 10-30-92, cert. ef. 11-1-92
HR 27-1992(Temp), f. & cert. ef. 9-1-92
HR 8-1992, f. 2-28-92, cert. ef. 3-1-92
HR 43-1991, f. & cert. ef. 10-1-91
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0800
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89
AFS 56-1987, f. 10-29-87, cert. ef. 11-1-87; Renumbered from 461-014-0056
AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86
AFS 29-1985, f. 5-22-85, cert. ef. 5-29-85
AFS 48-1984(Temp), f. 11-30-84, cert. ef. 12-1-84
AFS 57-1983, f. 11-29-83, cert. ef. 1-1-84

Or. Admin. R. 410-130-0700 HCPCS Supplies and DME

(1) Use appropriate HCPCS codes to bill all supplies and DME.

(2) For items that do not have specific HCPCS codes:

(a) Use unlisted HCPCS code;

(b) Bill at acquisition cost, purchase price plus postage.

(3) CPT code 99070 is no longer billable for supplies and materials. Use HCPCS codes.

(4) Use S3620 with modifier TC for lost newborn screening (NBS) kits.

(5) The Division of Medical Assistance Programs (Division) bundles reimbursement for office surgical suites and office equipment in the reimbursement of surgical procedures.

(6) Contraceptive Supplies — Refer to OAR 410-130-0585.

(7) A4000–A9999:

(a) Certain codes in this range are bundled or otherwise not eligible for separate payment under the division’s Fee-for-Service Medical-Surgical program. HCPCS supplies and DME that are eligible for billing under A4000-A9999 codes, must be billed in accordance with the criteria set forth in OAR 410-130-0220;

(b) Do not use A4570, A4580 and A4590 for splint and cast materials. Use codes Q4001–Q4051;

(c) A9150-A9999 (administrative, investigational, and miscellaneous) are not covered, except for A9500-A9699. Refer to OAR 410-130-0680.

(8) B4000–B9999:

(a) HCPCS codes B4034–B4036 and B4150–B9999 are not covered for medical-surgical providers;

(b) Refer these services to home enteral/parenteral providers.

(9) C1000–C9999 are not covered.

(10) E0100–E1799: Division covers only the following DME HCPCS codes for medical-surgical providers when provided in an office setting:

(a) E0100–E0116;

(b) E0602;

(d) E1399;

(e) Refer all other items with "E" series HCPCS codes to DME providers.

(11) J0000–J9999 HCPCS codes — Refer to OAR 410-130-0180 for coverage of drugs.

(12) K0000–K9999 HCPCS codes — Refer all items with "K" series to DME providers.

(13) L0000–L9999:

(a) Refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies program Administrative rules for coverage criteria for orthotics and prosthetics;

(b) Certain “L” codes are bundled or otherwise do not pay separately. L codes must be billed in accordance with the criteria set forth in OAR 410-130-0220;

(A) Measurements;

(B) Moldings;

(D) Adjustments;

(E) Fittings;

(F) Casting and impression materials.

(d) Evaluation and Management codes are covered only for the diagnostic visit where the medical appropriateness for the orthotic is determined and for follow-up visits unrelated to the fitting of the orthotic.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 19-2026, amend filed 06/03/2026, effective 06/03/2026
DMAP 1-2026, temporary amend filed 01/20/2026, effective 01/20/2026 through 07/18/2026
OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 51-2002, f. & cert. ef. 10-1-02
OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02
OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 4-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 17-1999, f. & cert. ef. 4-1-99
OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98
HR 4-1997, f. 1-31-97, cert. ef. 2-1-97
HR 42-1994, f. 12-30-94, cert. ef. 1-1-95
HR 6-1994, f. & cert. ef. 2-1-94
HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0810
AFS 48-1989, f. & cert. ef. 8-24-89
AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89, Renumbered from 461-014-0056
AFS 56-1987, f. 10-29-87, cert. ef. 11-1-87
AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86
AFS 29-1985, f. 5-22-85, cert. ef. 5-29-85
AFS 48-1984(Temp), f. 11-30-84, cert. ef. 12-1-84
AFS 57-1983, f. 11-29-83, cert. ef. 1-1-84

Division 131 PHYSICAL AND OCCUPATIONAL THERAPY SERVICES

Or. Admin. R. 410-131-0040 Physical and Occupational Therapy

(1) The Division's Physical and Occupational Therapy (PT/OT) Services rules are designed to assist licensed physical and occupational therapists deliver health care services and prepare health claims for clients with medical assistance program coverage. The limits, authorization, and plan of treatment criteria apply to both rehabilitative and habilitative therapy. The definition for both is the following:

(2) A total of 30 visits per year of rehabilitative therapy and a total of 30 visits per year of habilitative therapy (physical and occupational therapy) are included on these lines when medically appropriate. Additional visits, not to exceed 30 visits per year of rehabilitative therapy and 30 visits per year of habilitative therapy, may be authorized in cases of a new acute injury, surgery, or other significant change in functional status. Children under age 21 may have additional visits authorized beyond these limits if medically appropriate, as per guideline note 6 of the Prioritized List of Health Services.

(3) OAR 410-131-0040 through 0160:

(a) Apply to services delivered by home health agencies and by hospital-based therapists in the outpatient setting. Billing and reimbursement for therapy services delivered by home health agencies and hospital outpatient departments must comply with the rules in their respective provider guides;

(b) Do not apply to services provided to hospital inpatients; and

(c) May not limit or effect any obligations of a school district or education entity eligible for reimbursement for covered, health-related services provided in support of a child with a disability education program required by state and federal law. School-sponsored services are supplemental to other health plan therapy services and are not considered duplicative. (See OAR chapter 410 division 133 SBHS rules for services provided by public education providers and OAR 410-141-3830 (Managed Care Entity (MCE) Billing and Payment).

(4) The Division shall enroll only the following types of providers as performing providers under the PT/OT program:

(a) An individual licensed by the relevant state licensing authority to practice physical therapy; and

(b) An individual licensed by the relevant state licensing authority to practice occupational therapy.

(5) All Division rules are intended to be used in addition to the General Rules for Health Systems Division programs (OAR 410 division 120) and the Oregon Health Plan (OHP) (OAR 410 division 141).

(6) The Oregon Health Evidence Review Commission’s (HERC) Prioritized List of Health Services is found in OAR 410-141-0520 and defines the covered services.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 133-2024, minor correction filed 11/04/2024, effective 11/04/2024
DMAP 15-2020, temporary amend filed 03/26/2020, effective 03/26/2020 through 09/21/2020
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 19-2017, f. & cert. ef. 6-9-17
DMAP 70-2016(Temp), f. 12-5-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 35-2011, f. 12-13-11, cert. ef. 1-1-12
HR 8-1991, f. 1-25-91, cert. ef. 2-1-91

Or. Admin. R. 410-131-0080 Therapy Plan of Care and Record Requirements

(1) There must be a rehabilitative or habilitative therapy plan of care to receive payment.

(2) The Division shall authorize for the level of care or type of service that meets the client’s medical need consistent with the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List) and guideline notes.

(3) The rehabilitative or habilitative therapy plan must adhere to the licensing board requirements of care and shall include:

(a) Client's name, ICD diagnosis code, and type, amount, frequency, and duration of the proposed rehabilitative or habilitative therapy;

(b) Individualized, measurably objective functional goals;

(d) Plan to address implementation of a home management program as appropriate from the initiation of therapy forward;

(e) Dated signature of the therapist or the prescribing practitioner establishing the therapy plan of care; and

(f) For home health clients, any additional requirements included in OAR chapter 410 division 127.

(4) The therapy treatment plan and regimen shall be taught to the client, family, foster parents, or caregiver during the therapy treatments. The client must be present for demonstrating therapy during teaching to assure therapy regimen is performed safely and correctly. The division may not authorize extra treatments for teaching.

(5) A therapy plan must comply with the relevant state licensing authority’s standards.

(6) If a state licensing authority has not adopted therapy plan of care standards, the therapy plan of care shall include:

(a) The need for continuing rehabilitative or habilitative therapy clearly stated;

(b) Changes to the rehabilitative or habilitative therapy plan of care, including changes to duration and frequency of intervention; and

(c) Any changes or modifications to the therapy plan of care shall be documented, signed, and dated by the prescribing practitioner or therapist who developed the plan.

(7) Therapy records shall include:

(a) A written referral, including:

(A) The client's name;

(B) The ICD-10-CM diagnosis code; and

(b) A copy of the signed therapy plan of care must be on file in the provider's therapy record prior to billing for services;

(c) Documents, evaluations, re-evaluations, and progress notes to support the rehabilitative or habilitative therapy treatment plan and prescribing provider's written orders for changes in the therapy treatment plan;

(d) Modalities used on each date of service;

(e) Procedures performed, and amount of time spent performing the procedures, documented and signed by the therapist; and

(f) Documentation of splint fabrication and time spent fabricating the splint.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 688.135 & 414.065
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 19-2017, f. & cert. ef. 6-9-17
DMAP 70-2016(Temp), f. 12-5-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 65-2014, f. 10-30-14, cert. ef. 11-4-14
DMAP 35-2011, f. 12-13-11, cert. ef. 1-1-12
OMAP 39-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 41-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 18-1999, f. & cert. ef. 4-1-99
HR 19-1992, f. & cert. ef. 7-1-92
HR 8-1991, f. 1-25-91, cert. ef. 2-1-91

Or. Admin. R. 410-131-0120 Limitations of Coverage and Payment

(1) The provision of PT/OT evaluations and therapy services require a prescribing practitioner referral, and services shall be supported by a therapy plan of care signed and dated by the prescribing practitioner as specified in 42 CFR 440.110.

(2) PT/OT initial evaluations and re-evaluations do not require PA and are not subject to prepayment review (PPR), but are limited to the following:

(a) Up to two initial evaluations in any 12-month period; and

(b) Up to four re-evaluation services in any 12-month period.

(3) Reimbursement is limited to the initial evaluation when both the initial evaluation and a re-evaluation are provided on the same day.

(4) School-sponsored therapy services are considered supplemental to other plan-covered therapy services that the student receives. School-based therapy services may not apply toward the client’s maximum therapy allowances. (See OAR chapter 410, division 133 SBHS rules.)

(5) All other occupational and physical therapy treatments are subject to PPR and require PA following 30 visits in a calendar year. See OAR 410-131-0160.

(6) A licensed occupational or physical therapist or a licensed occupational or physical therapy assistant under the supervision of a therapist shall be in constant attendance while therapy treatments are performed:

(a) Rehabilitative and habilitative therapy treatments may not exceed one hour per day each for occupational and physical therapy;

(b) Modalities:

(A) Are subject to PPR and require PA following 30 habilitative and 30 rehabilitative visits in a calendar year;

(B) Up to two modalities may be authorized on the day of treatment;

(D) Each individual supervised modality code may be reported only once for each client encounter.

(c) Massage therapy is limited to two units per day of treatment and shall be authorized only in conjunction with another therapeutic procedure or modality.

(7) Supplies and materials for the fabrication of splints shall be billed at the acquisition cost, and reimbursement may not exceed the Division’s maximum allowable in accordance with the physician fee schedule. Acquisition cost is purchase price plus shipping. Off-the-shelf splints, even when modified, are not included in this service.

(8) The following services are not covered under this rule:

(a) Services not medically appropriate;

(b) Services that are not paired with a funded diagnosis on the HERC‘s Prioritized List pursuant to OARs 410-141-3820 and 410-141-3830;

(d) Back school and back education classes;

(e) Services included in OAR 410-120-1200 (Excluded Services Limitations);

(f) Durable medical equipment and medical supplies other than the following splint supplies:

(A) Application of splints:

(i) 29105 Application of long arm splint (shoulder to hand);

(ii) 29125 Application of non-moveable, short arm splint (forearm to hand);

(iii) 29126 Application of moveable, hinged short arm splint (forearm to hand);

(iv) 29130 Application of non-moveable, hinged finger splint;

(v) 29131 Application of moveable, hinged finger splint.

(B) Supplies to create splints:

(i) Q4017 Cast supplies, long arm splint, adult (11 years +), plaster;

(ii) Q4018 Cast supplies, long arm splint, adult (11 years +), fiberglass;

(iii) Q4019 Cast supplies, long arm splint, pediatric (0-10 years), plaster;

(iv) Q4020 Cast supplies, long arm splint, pediatric (0-10 years), fiberglass;

(v)Q4021 Cast supplies, short arm splint, adult (11 years +), plaster;

(vi) Q4022 Cast supplies, short arm splint, adult (11 years +), fiberglass;

(vii) Q4023 Cast supplies, short arm splint, pediatric (0-10 years), plaster;

(viii) Q4024 Cast supplies, short arm splint, pediatric (0-10 years), fiberglass;

(ix) Q4049 Finger splint, static;

(x) Q4051 Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies).

(9) Physical capacity examinations are not a part of the PT/OT program but may be reimbursed as administrative examinations when ordered by the local branch office. See OAR chapter 410, division 150 for information on administrative examinations and report billing.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 134-2024, minor correction filed 11/04/2024, effective 11/04/2024
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 101-2018, minor correction filed 11/28/2018, effective 11/28/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 56-2017, amend filed 12/26/2017, effective 01/01/2018
DMAP 37-2017(Temp), f. 9-15-17, cert. ef. 10-1-17 thru 3-29-18
DMAP 19-2017, f. & cert. ef. 6-9-17
DMAP 70-2016(Temp), f. 12-5-16, cert. ef. 1-1-17 thru 6-29-17
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 35-2011, f. 12-13-11, cert. ef. 1-1-12
OMAP 15-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 59-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 64-2003, f. 9-8-03, cert. ef. 10-1-03
OMAP 53-2002, f. & cert. ef. 10-1-02
OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 18-1999, f. & cert. ef. 4-1-99
OMAP 8-1998, f. & cert. ef. 3-2-98
HR 2-1997, f. 1-31-97, cert. ef. 2-1-97
HR 43-1994, f. 12-30-94, cert. ef. 1-1-95
HR 28-1993, f. & cert. ef. 10-1-93
HR 19-1992, f. & cert. ef. 7-1-92
HR 8-1991, f. 1-25-91, cert. ef. 2-1-91

Or. Admin. R. 410-131-0160 Prepayment Review (PPR) and Prior Authorization (PA) for Payment

(1) Most OHP clients have prepaid health services contracted for by the Authority through enrollment in a Managed Care Entity (MCE).

(2) The provider shall verify whether an MCE or the Division is responsible for reimbursement. Refer to OAR 410-120-1140 Verification of Eligibility and Coverage.

(3) If a client is enrolled in an MCE, there may be PA requirements for some services that are provided through the MCE. Providers shall comply with the MCE’s PA requirements or other policies necessary for reimbursement from the MCE before providing services to any OHP client enrolled in an MCE. The physical or occupational therapy (PT/OT) provider shall contact the client’s MCE for specific instructions.

(4) A PT/OT provider assumes full financial risk in providing services to a FFS client in providing services that are not in compliance with Oregon Administrative Rules. See also OAR 410-120-1320 Authorization of Payment.

(a) PT/OT initial evaluations and re-evaluations are not subject to PPR and do not require a PA;

(b) To ensure reimbursement of PT/OT services and procedures beyond the initial evaluation, the PT/OT provider must submit all required supporting documentation:

(A) Upon submission of the first claim in a series of claims in each therapy plan of care as established by prescribing practitioner per OAR 410-131-0080 for claims subject to PPR;

(B) Request a PA within five working days following 30 rehabilitative or 30 habilitative visits within a calendar year if additional visits are necessary:

(i) PA requests dated within five working days may be approved retroactively to include services provided within five days prior to the date of the PA request;

(ii) PA requests dated beyond five working days may not be authorized retroactively and if authorized shall be effective the date of the PA request. The Division recognizes the facsimile or postmark as the PA date of request.

(d) A PA is not required for Medicare-covered PT/OT services provided to dual-eligible clients (Medicare clients who are also Medicaid-eligible).

(5) If the service or item is subject to PPR or requiring PA, the PT/OT provider shall follow and comply with PPR and PA requirements in these rules and the General Rules, (OAR chapter 410, division 120) including but not limited to:

(a) The service is adequately documented (see OAR 410-120-1360 Requirements for Financial, Clinical and Other Records). Providers shall maintain documentation in the provider's files to adequately determine the type, medical appropriateness, or quantity of services provided;

(b) The services provided are consistent with the information submitted when authorization was requested;

(d) The services are provided within the timeframe specified on the authorization of payment document; and

(e) Includes the PA number on all claims for occupational and physical therapy services that require PA, or the Division shall deny the claim.

(6) The following services are subject to PPR when paired above the funding line on the HERC prioritized list (see OAR 410-141-3820) if visits have not exceeded the allowed 30 habilitative and 30 rehabilitative visits allowed in a calendar year:

(a) 95831 Manual muscle testing of arm, leg or trunk;

(b) 95832 Manual muscle testing of hand;

(d) 95834 Manual muscle testing of whole body including hands;

(e) 95851 Range of motion testing of arm, leg or each spine section;

(f) 95852 Range of motion testing of hand;

(g) 97012 Application of mechanical traction to 1 or more areas;

(h) 97022 Application of whirlpool therapy to 1 or more areas;

(i) 97036 Physical therapy treatment to 1 or more areas, Hubbard tank, each 15 minutes;

(j) 97110 Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes;

(k) 97112 Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes;

(L) 97113 Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes;

(m) 97116 Walking training to 1 or more areas, each 15 minutes;

(n) 97124 Therapeutic massage to 1 or more areas, each 15 minutes;

(o) 97140 Manual (physical) therapy techniques to 1 or more regions, each 15 minutes;

(p) 97150 Therapeutic procedures in a group setting (1 visit = 1 unit);

(q) 97530 Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes;

(r) 97532 Development of cognitive skills to improve attention, memory, or problem solving, each 15 minutes;

(s) 97535 Self-care or home management training, each 15 minutes;

(t) 97542 Wheelchair management, each 15 minutes;

(u) 97755 Assistive technology assessment to enhance functional performance, each 15 minutes; and

(v) 97761 Training in use of prosthesis for arms and/or legs, per 15 minutes.

(7) PA is required when:

(a) There is documented need for extended service, considering 60 minutes as the maximum length of a treatment session;

(b) There is documented need for continuing rehabilitative or habilitative therapy, considering 30 habilitative and 30 rehabilitative visits in a calendar year.

(c) Requesting services for treatments that are below the funded line or not otherwise excluded from coverage per OAR 410-141-3820.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
DMAP 135-2024, minor correction filed 11/04/2024, effective 11/04/2024
DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019
DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018
DMAP 56-2017, amend filed 12/26/2017, effective 01/01/2018
DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16
DMAP 35-2011, f. 12-13-11, cert. ef. 1-1-12
OMAP 59-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 92-2003, f. 12-30-03 cert. ef. 1-1-04
OMAP 53-2002, f. & cert. ef. 10-1-02
OMAP 41-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 18-1999, f. & cert. ef. 4-1-99
OMAP 8-1998, f. & cert. ef. 3-2-98
HR 2-1997, f. 1-31-97, cert. ef. 2-1-97
HR 43-1994, f. 12-30-94, cert. ef. 1-1-95
HR 28-1993, f. & cert. ef. 10-1-93
HR 19-1992, f. & cert. ef. 7-1-92
HR 8-1991, f. 1-25-91, cert. ef. 2-1-91, Renumbered from 461-023-0015
AFS 63-1987, f. 12-30-87, ef. 4-1-88
AFS 40-1984, f. 9-18-84, ef. 10-1-84
AFS 22-1984(Temp), f. & ef. 5-1-84
AFS 14-1984(Temp), f. & ef. 4-2-84
AFS 98-1982, f. 10-25-82, ef. 11-1-82
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 46-1982, f. 4-30-82, ef. 5-1-82
PWC 760, f. 9-5-75, ef. 10-1-75
PWC 706, f. 1-2-75, ef. 2-1-75

Division 132 PRIVATE DUTY NURSING SERVICES

Or. Admin. R. 410-132-0020 Private Duty Nursing Services

(1) The practice of nursing is governed by the following: Oregon State Board of Nursing, ORS 678.010 to 678.410, and Oregon State Board of Nursing, chapter 851, divisions 031, 045, and 047.

(2) Private duty nursing is considered supportive to the care provided to a client by the client's family, foster parents, and delegated caregivers, as applicable. Nursing services shall be medically appropriate. Medically appropriate for private duty nursing shift care is determined by qualifying for services based on the Private Duty Nursing Acuity Grid (DMAP 591). Increases or decreases in the level of care and number of hours or visits authorized shall be based on a change in the client’s condition, program limitations, and the family, foster parents, or delegated caregiver’s ability to provide care.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
OMAP 54-2002, f. & cert. ef. 10-1-02
OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 6-1999, f. 3-4-99, cert. ef. 4-1-99
HR 6-1997, f. & cert. ef. 2-19-97

Or. Admin. R. 410-132-0030 Definitions

(1) “Activities of daily living or ‘ADL’” means activities usually performed in the course of a normal day in an individual's life including:

(a) Eating: Assisting the individual in feeding or fluid intake by any means from a receptacle into the body, including monitoring to prevent choking or aspiration;

(b) Bathing: Assisting the individual with cleansing the body, washing hair, shaving, nail care, and using assistive devices when necessary to get in and out of the bathtub or shower;

(c) Dressing: Assisting the individual with putting on, fastening, and taking off all items of clothing, braces, and artificial limbs, including obtaining and replacing items from their storage area in the immediate environment;

(d) Toileting: Assisting the individual in getting to and from, on and off, the toilet, commode, or bedpan for elimination of feces and urine. This includes cleansing after elimination and adjusting clothing as necessary;

(e) Maintaining Continence: Including external cleansing of Foley catheter, emptying catheter drainage bag, maintenance bowel care, changing and replacing incontinence products, including colostomy or ileostomy bags;

(f) Transferring: Assisting the individual with mobility, transfers, and repositioning by any means including use of an assistive device and includes turning or adjusting padding for physical comfort or pressure relief and encouraging or assisting with range of motion exercises.

(2) “Admission” means acceptance of the client into the private duty nursing program contingent upon meeting the criteria as stated in rule.

(3) “Basic tasks of client/nursing care” means procedures that do not require the education or training of a registered nurse or licensed practical nurse that cannot be performed by the client independently. Basic tasks of client/nursing care also means procedures that may be directed by the client. These basic tasks include, but are not limited to, activities of daily living. Basic tasks may vary from setting to setting depending on the client population served in that setting and the acuity and complexity of the client's care needs. Basic tasks may require the assignment and supervision of a licensed nurse. The need for supervision is at the discretion of the registered nurse. See State Board of Nursing rules that govern the practice of nursing.

(4) “Critical/fluctuating condition” means a situation where the client's clinical and behavioral state is of a serious nature expected to rapidly change and be in need of continuous reassessment and evaluation.

(5) “Delegation” means that a registered nurse authorizes an unlicensed person to perform tasks of nursing care in selected situations and indicates that authorization in writing. The delegation process includes nursing assessment of a client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, ensuring supervision of the unlicensed persons, and re-evaluating the task at regular intervals. For the purpose of these rules, the unlicensed person, caregiver, or certified nursing assistant performs tasks of nursing care under the Registered Nurse’s delegated authority.

(6) “Discharge” means the client no longer meets the Division rules and criteria of the private duty nursing program.

(7) “Habilitation” means services that are provided in order to assist an individual to acquire a variety of skills including self-help, socialization, and adaptive skills. Habilitation is aimed at raising the level of physical, mental, and social functioning of an individual. Habilitation is contrasted to rehabilitation, which involves the restoration of function an individual lost.

(8) “Home” means a place of temporary or permanent residence, not including a hospital, intermediate care facility for individuals with intellectual disabilities (ICF/ID), nursing facility, or licensed residential care facility.

(9) “Instrumental activities of daily living or ‘IADL’” means activities usually performed in the course of a normal day in an individual's life and include:

(a) Personal Hygiene: Perform or assist with activities required to keep one’s appearance neat, secure clothing, comb/brush hair, nail care, foot care, skin care, mouth care, and oral hygiene, etc.;

(b) Light Housework: Perform or assist with housekeeping tasks necessary to maintain the individual in a healthy and safe living environment;

(d) Meal Preparation: Perform or assist with healthy meal planning and preparation, insuring special diets are followed;

(e) Transportation: Assist the individual in getting to and from necessary appointments and community activities through available means of transportation;

(f) Grocery Shopping: Perform or assist the individual in planning for and purchasing basic needs and household items;

(g) Using the Telephone: Perform or assist the individual in arranging necessary appointments and making desired phone calls;

(h) Medication Management: Assist with medications that are ordinarily self-administered, including administering medication and observing to insure the individual is taking medication as ordered, documenting and monitoring any notable side effects, and refilling prescriptions in a timely manner. Assist with use, maintenance, and cleaning of in-home equipment, monitoring client’s condition, and ordering and maintaining necessary supplies;

(i) Money Management: Perform or assist with budgeting, making payments for monthly expenses, and use of personal funds for desired items and activities.

(10) “Maintenance care” means the level of care needed when the goals and objectives of the care plan are reached, the condition of the client is stable or predictable, the plan of care does not require the skills of a licensed nurse in continuous attendance, or the client, family, foster parents, or caregivers have been taught and have demonstrated the skills and abilities to carry out the plan of care.

(11) “Medically Fragile Children's (MFC) program” means a Department of Human Services (Department) organizational unit that coordinates and funds appropriate services for children ages 0 to 18 years with intensive medical needs that require in-home and technological supports and meet MFC clinical criteria.

(12) “Member of the household” means any individual sharing a common home as part of a single family unit, including domestic employees and others who live together as part of a family unit, but not including a roomer or boarder.

(13) “Plan of care” means written instructions detailing how the client is to be cared for. The plan is initiated by the private duty nurse or nursing agency with input from the prescribing physician. See the "Documentation Requirements" section of the Private Duty Nursing Services administrative rules.

(14) “Private duty nursing shift care” means an RN or LPN nursing service for the client's critical/fluctuating conditions requiring the need for reassessment and evaluation with a high probability that complications would arise without skilled nursing management of the treatment program supplied in a specified block of time.

(15) “Practice of nursing” means using the nursing process under doctor's orders to diagnose and treat human response to actual or potential health care problems, health teaching and health counseling, the provision of direct client care, and the teaching, delegation, and supervision of others who provide tasks of nursing care to clients. See State Board of Nursing rules that govern the practice of nursing.

(16) “Private duty nursing visit” means RN or LPN skilled nursing services for non-critical/stable conditions requiring reassessment and evaluation with a moderate probability that complications would arise without skilled nursing management of the treatment program supplied on an intermittent per visit basis.

(17) “Respite” means short-term or intermittent care and supervision in order to provide an interval of rest or relief to family or caregivers.

(18) “Responsible unit” means the agency responsible for approving or denying prior authorization.

(19) “Shift” means four to twelve hours of private duty nursing.

(20) “Skilled nursing services” means client care services pertaining to the curative, restorative, or preventive aspects of nursing performed by or under the supervision of a registered nurse pursuant to the plan of care established by the physician in consultation with the registered nurse. Skilled nursing emphasizes a high level of nursing direction, observation, and skill. The focus of these services shall be the use of the nursing process to diagnose and treat human responses to actual or potential health care problems, health teaching, and health counseling. Skilled nursing services include the provision of direct care and the teaching, delegation, and supervision of others who provide tasks of nursing care to clients. These services shall comply with the Nurse Practice Act and administrative rules of the Oregon State Board of Nursing.

(21) “Special tasks of client/nursing care” means tasks that require the education and training of a registered nurse or licensed practical nurse to perform. Special tasks may vary from setting to setting depending on the client population served in that setting and the acuity/complexity of the client's care needs. Examples of special tasks include, but are not limited to, administration of injectable medications, suctioning, and complex wound care.

(22) “Stable/predictable condition” means a situation in which the client's clinical and behavioral status is known and does not require the regularly scheduled presence and evaluation of a licensed nurse. See State Board of Nursing rules that govern the practice of nursing.

(23) “Teaching” means the registered nurse instructs an unlicensed person in the correct method of performing a selected task of client/nursing care. See State Board of Nursing rules that govern the practice of nursing.

(24) "Unlicensed Person" means an individual who is not licensed to practice nursing, medicine, or any other health occupation requiring a license in Oregon, but who provides tasks of nursing care or is taught to administer non-injectable medications. A certified nursing assistant, as defined by these rules, is an unlicensed person. For the purpose of these delegation rules, unlicensed persons do not include members of the client's immediate family. Family members may perform tasks of nursing care without specific delegation from a Registered Nurse. The terms "unlicensed person" and "caregiver" may be used interchangeably.

(25) “Visit” means nursing service supplied on an intermittent basis in the home.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
OMAP 6-1999, f. 3-4-99, cert. ef. 4-1-99
HR 6-1997, f. & cert. ef. 2-19-97

Or. Admin. R. 410-132-0060 Private Duty Nursing Transition into Maintenance

(1) Private duty nursing services become maintenance care when any one of the following situations occurs:

(a) Medical and nursing documentation supports that the condition of the client is stable/predictable;

(b) The plan of care does not require a licensed nurse to be in continuous attendance;

(c) The client, family, foster parents, or caregivers have been taught the nursing services and have demonstrated the skills and ability to carry out the plan of care;

(d) The combined score on the Acuity Grid and Psychosocial Grid is less than 54.

(2) This rule does not apply to individuals in the MFC program.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
HR 6-1997, f. & cert. ef. 2-19-97
HR 9-1991, f. 1-28-91, cert. ef. 3-1-91

Or. Admin. R. 410-132-0070 Documentation Requirements

(1) Documentation of services provided shall be maintained in the client's place of residence by the private duty nurse until discharged from service. Payment may not be made for services where the documentation does not support the definition of skilled nursing. Documentation shall meet the standards of the Oregon State Board of Nursing.

(2) The private duty nurse shall ensure completion and documentation of a comprehensive assessment of the client's capabilities and needs for nursing services within seven days of admission. Comprehensive assessments shall be updated and submitted to the responsible unit by the next work day after any significant change of condition and reviewed by the responsible unit within the Oregon Health Authority at least every 60 days. Some examples of significant change in condition are hospital admission, emergency room visit, and change in status, death, or discharge from care.

(3) The nursing care plan shall document that the private duty nurse, through case management and coordination with all interdisciplinary staff and agencies, provides services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each client in accordance with a written, dated, nursing care plan. The nursing care plan shall:

(a) Be completed within seven days after admission for children and adolescents with short-term needs who are served through the Division. The nursing care plan shall be reviewed, updated, and submitted whenever the client's needs change, but at least every 60 days;

(b) Describe the medical, nursing, and psychosocial needs of the client and how the private duty nurse will actively coordinate and facilitate meeting those needs. This description of needs shall include interventions, measurable objectives, goals, and time frames in which the goals and objectives will be met and by whom;

(c) Include the rehabilitation potential including functional limitations related to Activities of Daily Living (ADL), types and frequency of therapies, and activity limitations per physician order;

(d) Include services related to school-based care according to the IEP and the Individualized Family Service Plan, if applicable;

(e) Show coordination of all services being provided including, but not limited to, the client or representative, registered nurse (RN) case manager, Department case worker, physician, other disciplines involved, and all other care providers involved in the client's treatment plan;

(f) Include a statement of the client's potential toward discharge. Timelines shall be included in the plan outline;

(g) Be available to and followed by all caregivers involved with the client’s care.

(4) Documentation of private duty shift care and responses to care shall be written in an accurate, timely, thorough, and clear manner on the narrative or flow sheet. Documentation shall comply with the requirements of the Oregon State Board of Nursing in OAR chapter 851 and shall include:

(a) The name of the client on each page of documentation;

(b) The date of service;

(d) Anything unusual from the standard plan of care shall be expanded on the narrative;

(e) Interventions;

(f) Outcomes including the client’s response to services delivered;

(g) Nursing assessment of the client's status and any changes in that status per each working shift; and

(h) Full signature of provider.

(5) Documentation of delegation, teaching, and assignment shall be in accordance with the Oregon State Board of Nursing Rules.

(6) For documentation to be submitted with prior authorization, see OAR 410-132-0100.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00
HR 6-1997, f. & cert. ef. 2-19-97

Or. Admin. R. 410-132-0080 Limitations

(1) General pertains to both shift care and visits:

(a) Private duty nursing is not covered if the client is:

(A) Twenty-one years of age or older;

(B) A resident of a nursing facility;

(D) In a hospital;

(E) In a licensed residential care facility;

(b) Private duty nursing is not covered solely to allow the client's family or caregiver to work or go to school;

(d) Payment for private duty nursing may not be authorized for parents, siblings, grandparents, foster care parents, significant others, members of the client's household, or individuals paid by other agencies to provide caregiving services;

(e) Costs of private duty nursing services are not reimbursable if they are provided concurrently with care being provided under home health or hospice program rules;

(f) Home nursing visits as defined in the Home Enteral/Parenteral Nutrition and IV Services rules are not covered in conjunction with private duty nursing services;

(g) These services are provided for individuals aged 0 to 21 who need PDN or the same or similar nursing services during school hours. These services are provided through the school-based health services program in conjunction with the individual’s Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP) under the Individuals with Disabilities Education Act (IDEA;

(h) Holidays are paid at the same rate as non-holidays;

(i) Hours nurses spend in training are not reimbursable;

(j) Travel time to reach the job site is not reimbursable;

(k) Maintenance care is not reimbursable, except for those individuals in the MFC program.

(2) Private duty nursing visit:

(a) The nursing care plan and documentation supporting the medical appropriateness for private duty nursing shall be reviewed every 60 days to continue the service for children and adolescents with short-term needs who are served by the Division. Reviews shall be conducted by the responsible unit;

(b) Private duty nursing visits are limited to two per day.

(3) Private duty nursing shift care:

(a) Medically appropriate private duty nursing shift care for clients up to 21years old may be covered for acute episodes of illness, injury, or medical condition up to 60 continuous days in cases where it has been determined that skilled management by a licensed nurse is required;

(b) A client may be referred to the MFC program to determine if they meet the criteria for program admission at the time of the initial request for services if any of the following are determined to exist:

(A) The client's medical needs are for habilitation or maintenance; or

(B) The client's medical needs are long term.

(c) Individuals who no longer qualify for private duty nursing shift care shall be referred to the Department for determination of their long-term care needs;

(d) The number of hours of private duty nursing services that a client may receive is determined by the score on the Private Duty Nursing Acuity Grid (DMAP 591):

(A) The client shall score greater than 60 points on the Acuity Grid to receive up to 24 hours per day immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or

(B) The client shall score 50 to 60 points on the Acuity Grid to receive up to 16 hours per day immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or

(C) The client shall score 40 to 49 points on the Acuity Grid to receive up to 84 hours per week immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or

(D) If the score is 30 to 39 on the Acuity Grid, then the Private Duty Nursing Psychosocial Grid (DMAP 590) shall be used to determine eligibility. If the score is 24 or above, the client may receive up to 84 hours per week of shift care.

(e) The banking, saving, or accumulating unused prior authorized hours used for the convenience of the family or caregiver is not covered.

History

Statutory/Other Authority: 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
OMAP 54-2002, f. & cert. ef. 10-1-02
OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99
HR 6-1997, f. & cert. ef. 2-19-97
HR 5-1996, f. & cert. ef. 5-1-96
HR 13-1995, f. 6-2-95, cert. ef. 6-15-95
Reverted to HR 9-1991, f. 1-28-91, cert. ef. 3-1-91
HR 25-1992(Temp), f. & cert. ef. 8-18-92
HR 9-1991, f. 1-28-91, cert. ef. 3-1-91

Or. Admin. R. 410-132-0100 Prior Authorization

(1) Private duty nursing providers shall obtain prior authorization (PA) for all services.

(2) Providers shall request PA as follows (see the Private Duty Nursing Services Supplemental Information booklet for contact information):

(a) For individuals served by the MFC), from the Department‘s MFC Program;

(b) For clients enrolled in the fee-for-service (FFS) Medical Case Management (MCM) program, from the MCM contractor;

(d) For all other clients, from the Division.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 93-2003, f. 12-30-03 cert. ef. 1-1-04
OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99
HR 6-1997, f. & cert. ef. 2-19-97
HR 9-1991, f. 1-28-91, cert. ef. 3-1-91, Renumbered from 461-019-0210
AFS 40-1984, f. 9-18-84, ef. 10-1-84
AFS 22-1984(Temp), f. & ef. 5-1-84
AFS 14-1984(Temp), f. & ef. 4-2-84
AFS 9-1983, f. 2-17-83, ef. 3-2-83
AFS 52-1982, f. 5-28-82, ef. 6-30-82
AFS 43-1982, f. 4-29-82, ef. 5-1-82
PWC 799, f. & ef. 6-1-76
PWC 759, f. 9-5-75, ef. 10-1-75
PWC 681, f. & ef. 7-17-74

Or. Admin. R. 410-132-0120 Billing Information

(1) If the client has not enrolled in a CCO or PHP, bill with the appropriate Division unique procedure codes and follow the instructions on how to complete the CMS-1500.

(2) Client copayments may be required for certain services. See OAR 410-120-1230 for specific details.

(3) Claims shall be submitted on a CMS-1500, electronically or on paper. Paper claims shall be sent to the Division.

(4) Contact the Division’s Electronic Billing Representative for information about electronic billing.

(5) Bill on a CMS-1500 and enter the appropriate TPR Explanation Code in Field 9 when billing for clients with Medicare.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
OMAP 54-2002, f. & cert. ef. 10-1-02
HR 6-1997, f. & cert. ef. 2-19-97
HR 9-1991, f. 1-28-91, cert. ef. 3-1-91

Or. Admin. R. 410-132-0180 Procedure Codes

(1) All private duty nursing services require prior authorization.

(2) Private duty nursing visit:

(a) T1030 — Nursing care in the home by registered nurse per diem;

(b) T1031 — Nursing care in the home by licensed practical nurse per diem.

(3) Private duty nursing shift care:

(a) S9123 — Nursing care in the home by registered nurse per hour — 1 unit equals one hour;

(b) S9124 — Nursing care in the home by licensed practical nurse per hour — 1 unit equals one hour.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 54-2002, f. & cert. ef. 10-1-02
OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00
HR 6-1997, f. & cert. ef. 2-19-97
HR 9-1991, f. 1-28-91, cert. ef. 3-1-91

Or. Admin. R. 410-132-0200 Provider Enrollment

(1) Registered nurses and licensed practical nurses shall submit a copy of licensure every two years upon renewal by the Oregon State Board of Nursing to be enrolled or continue enrollment as a Division provider.

(2) If the Division provider is a nursing employment/staffing agency, the agency shall:

(a) Be licensed in the State of Oregon as an in-home care agency with a comprehensive licensure as defined in OAR 333-536 or Home Health Agency OAR 333-027;

(b) Conduct a background check through the Department CRIMS;

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 45-2015, f. & cert. ef. 8-25-15
OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99

Division 133 SCHOOL-BASED HEALTH SERVICES

Or. Admin. R. 410-133-0000 Purpose

(1) School-Based Health Services (SBHS) rules:

(a) Define Oregon’s fee-for-service Medicaid program administered by the Oregon Health Authority (Authority) to reimburse publicly funded education agencies for health services provided in education settings to Oregon’s Medicaid-enrolled children and young adults.

(b) Define when Medicaid-covered services are reimbursable to education agencies.

(d) Cite and align with federal and state requirements and limitations including:

(A) Individuals with Disabilities Education Act (IDEA);

(B) Section 504 of the Rehabilitation Act of 1973;

(D) Oregon Revised Statutes; and

(E) Oregon Administrative Rules (OARs).

(2) These SBHS rules are to be used in conjunction with:

(a) Medical Assistance Programs rules in OARs Chapter 410, Divisions 120 and 141;

(b) The Authority provider rules in OARs Chapter 943, Division 120; and

(A) OARs Chapter 581, Divisions 15, 21, and 22; and

(B) OARs Chapter 584, Divisions 220 and 245.

(3) Medicaid-enrolled children and young adults retain the ability to obtain services from any qualified Medicaid provider. These rules do not require Medicaid-enrolled children and young adults to receive their health services only from school medical providers.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 31-2003, f. & cert. ef. 4-1-03
OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 38-1999, f. & cert. ef. 10-1-99
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0040 Definitions

In addition to the definitions in OAR 410-120-0000 and OAR 410-141-0001, the following definitions apply to these rules:

(1) “Adapted vehicle” means a vehicle that has been physically adjusted or designed to meet the needs of the individual student under IDEA (e.g., special harnesses, wheelchair lifts, ramps, specialized environmental controls, etc.) to accommodate students with disabilities. Special physical adaptations may also include air conditioning and specialized suspension systems.

(2) “Assessment” means an SBHS-recognized provider’s process of obtaining information regarding an individual’s health status. Assessment is process-oriented, focusing on measuring an individual's abilities and providing feedback for improvement.

(3) “Assistive technology” means any item, piece of equipment, software program, or product that is used to increase, maintain, or improve functional capabilities to aid an individual with disabilities or functional limitations to perform tasks.

(4) “Behavioral health” has the same meaning as defined in OAR 410-172-0600.

(5) “Behavioral health supports” means a broad range of mental health wellness supports for students with social and/or relational health needs. Supports may include social skills training or groups, regular check-ins with school staff, development of behavior intervention plans, substance use prevention groups, supporting essential health and well-being needs (such as food insecurity or housing), referral to treatment, and/or coordination with community providers.

(6) “Behavioral health treatment” means intensive services for children or young adults with identified mental health or substance use needs. Treatment may include therapeutic interventions such as individual or family therapy sessions, intensive treatment groups related to specific mental health or substance use needs, or risk assessments and safety planning for students experiencing suicidal ideation or other acute behavioral health crises.

(7) “Care coordination” means the act and responsibility to deliberately organize culturally and linguistically appropriate services, care activities, and information sharing among all participants involved with a child or young adult’s care according to their physical, developmental, behavioral, dental and social needs. Care coordination involves organizing care activities, sharing information, and consultation to ensure and deliver safe and effective care aligned with the child or young adult’s needs. Care coordination includes but is not limited to training and supervision and communicating and sharing information with the child or young adult’s parent/guardian, physician, community practitioner(s), community organization(s), coordinated care organization (CCO), and staff.

(8) “Case Management Services” means services provided to ensure a child or young adult obtains health services necessary to maintain physical, behavioral, and emotional development and oral health. Case management services include a comprehensive, ongoing assessment of medical, behavioral, or dental needs plus the development and implementation of a plan to obtain or make referrals for needed medical, behavioral, or dental services, referring members to community services and supports.

(9) “Centers for Medicare and Medicaid Services (CMS)” means the federal regulatory agency for Medical Assistance Programs, including Medicaid.

(10) “Child or young adult” means an individual from birth through the school year in which they turn 21.

(11) “Delegation process” has the same meaning as defined in OAR 851-006-0011. The delegation process must be completed in compliance with OAR Chapter 851, Division 47 Standards for Registered Nurse Delegation Process.

(12) “Diagnosis code” has the same meaning as defined in OAR 410-120-0000.

(13) “Early and Periodic Screening, Diagnostic and Treatment (EPSDT)” has the same meaning as defined in OAR 410-120-0000.

(14) “Early Intervention/Early Childhood Special Education (EI/ECSE)” has the same meaning as defined in OAR 581-015-2000.

(15) “Education agency” means, for the purposes of these rules, a public school district, EI/ECSE contractor or subcontractor, education service district, or a state institution providing educational services or transition services (defined in OAR Chapter 581, Division 15) to children and young adults that receives state or federal funds either directly or by contract or subcontract with the Oregon Department of Education (ODE). The ODE is considered a local unit of government pursuant to 42CFR 433.51.

(16) “Education service district (ESD)” means a district created under ORS 334.010 that provides regional educational services to component school districts.

(17) “Evaluation” means an objective examination of an individual’s health status based upon well-defined criteria to inform health-related needs or diagnosis or for the purpose of planning treatment. See also re-evaluation services.

(18) “Federal Medical Assistance Percentage (FMAP)” means the federal government’s share of expenditures for the Medicaid and Children’s Health Insurance Program (CHIP) programs.

(19) “Health Evidence Review Commission (HERC)” has the same meaning as defined in OAR 410-120-0000.

(20) “Health Insurance Portability and Accountability Act of 1996 (HIPAA)” means the federal law (Public Law 104-191, August 21, 1996) with the legislative objective to assure health insurance portability, reduce health care fraud and abuse, enforce standards for health information, and guarantee security and privacy of health information.

(21) “Individual Plan of Care (IPOC)” means a prescriptive document for billing Medicaid for planned services provided to a child or young adult in education settings. To serve as the prescriptive document the plan must include the education agency’s name, the specific child or young adult’s first and last name, and each necessary and appropriate health service category including the nature, extent, or units of service and therapeutic value for each service. The IPOC may be an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) or any other established and documented individualized health or behavioral health plan if such document contains the necessary, prescriptive elements required to serve as the prescriptive document for billing Medicaid.

(22) “Individuals with Disabilities Education Act (IDEA) of 1975” means the federal law ensuring the rights of children with disabilities to a free and appropriate public education (FAPE).

(23) “Individualized Education Program (IEP)” has the same meaning as defined in 34 CFR 300.320.

(24) “Individualized Family Service Plan (IFSP)” has the same meaning as defined in 34 CFR 303.320.

(25) “Medicaid” has the same meaning as defined in OAR 410-120-0000.

(26) “Medicaid-enrolled” means an individual member or provider who is enrolled in Oregon’s Medicaid Program.

(27) “Medicaid Management Information System (MMIS)” means a statewide system that houses Medicaid data necessary for the business operations of Medicaid administration including, but not limited to, eligible member information, enrolled provider information, procedure and diagnosis codes, and claims data.

(28) “Medically Appropriate” has the same meaning as “EPSDT Medically Appropriate” in OAR 410-151-0001.

(29) “Medically Necessary” has the same meaning as “EPSDT Medically Necessary” in OAR 410-151-0001.

(30) “MMIS Provider Web Portal” means an electronic portal that allows Oregon Medicaid enrolled providers to log in and access relevant information to provide and be reimbursed for services provided to Oregon’s Medicaid-enrolled members. Medicaid-enrolled providers can use the portal to verify member eligibility and managed care assignment, access and query Oregon’s HERC Prioritized List of Health Services, submit and adjust claims for services provided, download claim remittance advices, and more. Non-enrolled providers can apply through the portal to enroll as an Oregon Medicaid provider.

(31) “National Provider Identifier (NPI)” has the same meaning as defined in OAR 410-120-0000.

(32) “Non-Billing Provider” has the same meaning as defined in OAR 410-120-0000.

(33) “Oregon Department of Education (ODE)” means the state agency that provides oversight to public education agencies for ensuring compliance with federal and state laws relating to education.

(34) “Oregon Health Authority (Authority)” has the same meaning as defined in OAR 410-120-0000.

(35) “Oregon Health Plan (OHP)” has the same meaning as defined in OAR 410-120-0000.

(36) “Personal care services” means the provision of, assistance with, or cueing for functional activities, physical or behavioral, that a child or young adult requires for their continued well-being. Personal care services include, but are not limited to, ambulation, mobility, transfers, and positioning, basic personal hygiene, continence/incontinence care, nutrition and feeding, medication management (including administration), redirection and intervention for behavior, and trained, assigned, or delegated services, including delegated nursing procedures. Personal care services are planned services included in an IPOC and deemed medically necessary and appropriate by a supervisory-level, SBHS-recognized provider within their scope of practice.

(37) “Planned services” means school-based health services that are provided pursuant to an IPOC. See also unplanned services.

(38) “Practitioner” means an individual licensed under state law to engage in the provision of health care services within the scope of the practitioner’s license or certification, including a ‘health care practitioner’ a ‘licensed health care practitioner’ or a ‘practitioner of the healing arts.’

(39) “Prioritized List of Health Services” has the same meaning as defined in OAR 410-120-0000.

(40) “Procedure code” means a code or codes used in the Healthcare Common Procedural Coding System (HCPCS) or Current Dental Terminology (CDT).

(41) “Re-evaluation” means an objective examination completed after an initial evaluation that focuses on the overall effectiveness of the current treatment, including progress toward current goals, modifying goals or treatment, or making a professional judgment to determine whether or not the child or young adult shall continue to receive one or more health-related services. Continuous monitoring of the child or young adult’s progress as a component of ongoing therapy services is not billable as a re-evaluation.

(42) "Referral" means the direction of an individual, based on the individual’s clinical needs and personal choice, to a facility or practitioner for a diagnostic test or health care treatment or service.

(43) “SBHS Documentation” means the combination of required information to bill direct services under the SBHS program including, but not limited to, service documentation and the Individual Plan of Care (IPOC), when applicable.

(44) “School medical provider” means an enrolled provider type that is established by the Authority to designate the provider eligible to receive Medicaid reimbursement for Medicaid-covered school-based health services. Authority-enrolled education agencies, as defined in this rule, are school medical providers.

(45) “Section 504 of The Rehabilitation Act of 1973” means a federal civil rights law, guided by the Americans with Disabilities Act (ADA), that protects qualified individuals from discrimination based on their disability.

(46) “Section 504 Accommodation Plan” means a formal plan that provides children and young adults with disabilities specific supports and accommodations needed to access the general education setting.

(47) “Specialized transportation” means transportation to a medically necessary service (as outlined in the IEP/IFSP of a Medicaid-enrolled child) provided in a specially adapted vehicle. In all cases, the medical need for physical or environmental adaptations during transport from home to school and back home must be identified in the IEP/IFSP.

(48) “Supervisory-level" means the SBHS-recognized provider is licensed or certified to practice independently and may supervise or train other SBHS-recognized providers.

(49) “Teacher Standards and Practices Commission (TSPC)” means the commission that governs licensing of teachers, personnel, service specialists, and administrators as set forth in OAR Chapter 584.

(50) “Transportation vehicle trip log” means a record or log kept specifically for tracking each transportation trip to or from a Medicaid-covered health service a Medicaid-eligible child or young adult receives.

(51) “Treatment Plan” means a licensed healthcare practitioner’s written plan of health services, including treatment with proposed location, frequency, and duration of treatment. A treatment plan must be written by a licensed healthcare practitioner within the scope of the practitioner's license or certification and in compliance with the practitioner’s respective Oregon board. Treatment plans may include but are not limited to behavioral health service plans (see OAR 309-019-0140), a registered nurse’s plan of care (see Oregon’s Nurse Practice Act, OARs Chapter 851), occupational therapy service plans (See OARs Chapter 339, Division 10), and physical therapy plans of care (see OARs Chapter 848, Division 40).

(52) “Unit” means a service measurement for billing and reimbursement efficiency.

(53) “Unplanned services” means the services and interventions that are urgent or immediate in nature and typically provided outside of services specified on an IPOC. Unplanned services may or may not lead to establishing an IPOC. See also planned services.

(54) “Unregulated Assistive Person (UAP)” has the same meaning as defined in OAR 851-006-0011.

(55) “Visit” means a service measurement of time for billing and reimbursement efficiency. For billing purposes, a visit is always presented as one (1) visit.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 6-2026, amend filed 02/11/2026, effective 02/11/2026
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020
DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert. ef. 4-1-03
OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 38-1999, f. & cert. ef. 10-1-99
OMAP 31-1998, f. & cert. ef. 9-1-98
HR 21-1995, f. & cert. ef. 12-1-95
HR 29-1993, f. & cert. ef. 10-1-93
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0050 Individual Plan of Care

(1) School-based health services, except unplanned services and screenings, must be provided pursuant to, in relation to, or in the development of a Medicaid-enrolled child or young adult’s Individual Plan of Care (IPOC).

(2) The IPOC must contain the following:

(a) The effective date of the IPOC. If a new IPOC is established, the new IPOC must indicate the new effective date, and an end date must be listed on the previous IPOC;

(b) The specific child or young adult’s first and last name;

(d) Each health service category including the nature, extent, or units of service and therapeutic value for each service.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, adopt filed 09/06/2024, effective 09/06/2024

Or. Admin. R. 410-133-0060 School-Based Health Services

(1) School-based health services are provided in education settings in support of a child or young adult’s education to address health-related service needs and devices that help the individual child or young adult keep, learn, or improve skills and functioning that adversely affect individual educational performance.

(2) Education agencies may be reimbursed for the following services subject to the requirements in OAR 410-133-0080 and 410-133-0090.

(a) Evaluations, re-evaluations, and assessments;

(b) Care coordination and referrals;

(d) Audiology services;

(e) Behavioral health services;

(f) Dental services;

(g) Diagnostic, screening, preventive, and rehabilitative services as set out in 42 CFR 440.130;

(h) Nursing services;

(i) Nurse Practitioner services;

(j) Occupational therapy services;

(k) Personal care services;

(l) Physical therapy services;

(m) Physician services;

(n) Specialized transportation services; and

(o) Speech-language pathology services.

(3) Medicaid-covered services provided to children and young adults ages 0-21 are not subject to Oregon’s Medicaid program’s HERC Prioritized List of Health Services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 38-1999, f. & cert. ef. 10-1-99
HR 22-1995, f. & cert. ef. 12-1-95
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0070 Telehealth

(1) The Authority may reimburse school medical providers for covered school-based health services delivered via telehealth that meet the following criteria:

(a) The covered telehealth service is provided to a child or young adult to the same extent that the service may be covered if it were provided in person;

(b) The school medical provider meets the following privacy and security standards:

(A) Prior to the delivery of the covered service using a telemedicine or telehealth modality, written, oral, or recorded consent is obtained and documented for the child or young adult to receive services using a telemedicine or telehealth delivery method. Documented or recorded consent must include:

(i) That information regarding the service and delivery method was provided in the language that the child or young adult or the parent or legal guardian understands. Consent must also be in the understood language.

(ii) The SBHS-recognized provider’s assessment of the child or young adult’s ability to access and participate in telemedicine or telehealth delivered services.

(B) Compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996; and

(C) Compliance with the Authority’s Privacy and Confidentiality Rules in OAR Chapter 943, Division 14 except as noted in section (4) below.

(c) Synchronous audio and visual interactive technologies are used, including interactive audio/telephonic services in a geographical area where synchronous audio and video is not available or consent for audio/video is refused for services provided; and

(d) The medium used to provide the telehealth is documented.

(2) The Authority shall provide reimbursement for a Medicaid-covered school-based telehealth service at the same reimbursement rate as if the service were provided in person.

(3) School-based telehealth service claims must include an appropriate telehealth modifier.

(4) In the event of a national or state declaration of emergency or in a prolonged school closure due to crisis, pandemic, or disaster, the Authority may modify the requirements for telehealth services to facilitate delivery of medically necessary service delivery. Modifications include, but are not limited to:

(a) Recognizing that exceptional circumstances may affect how all educational and related services and supports are provided, the Authority shall, to the extent possible based on the exceptional circumstance, follow guidance from the US Department of Health and Human Services (HHS), Office for Civil Rights (OCR), Office of Special Education Programs (OSEP) in the Department of Education, and Office of Special Education and Rehabilitative Services (OSERS) and may allow enforcement discretion related to encryption requirements; and

(b) Reimbursing a school-based health service delivered using a telehealth platform if:

(A) The telehealth service is medically necessary and appropriate;

(B) The delivery of the telehealth service reasonably approximates an in-person service; and

(C) Access to the telehealth service reduces barriers in the delivery of the health care service to accommodate the child or young adult’s health-related service needs.

History

Statutory/Other Authority: 413.042
Statutes/Other Implemented: 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, adopt filed 09/06/2024, effective 09/06/2024

Or. Admin. R. 410-133-0080 Coverage

(1) Services provided or supervised by Medicaid-enrolled SBHS-recognized providers are covered when EPSDT medical necessity and appropriateness are supported by:

(a) For planned services:

(A) The child or young adult’s IPOC; and

(B) The rendering provider’s service documentation.

(b) For unplanned services, the rendering provider’s service documentation which must include:

(A) Date of service;

(B) Medicaid-enrolled child or young adult’s:

(i) Full name;

(ii) Medicaid ID; and

(iii) Diagnosis code(s);

(D) Name of the rendering provider performing the service;

(E) Name of the healthcare provider supervising the service (when applicable);

(F) Medically necessary and appropriate need for the service;

(G) Location and duration of the service; and

(H) Nature, extent, or units of service.

(2) Specialized transportation services are covered when:

(a) The child or young adult requires specialized transportation to serve their individual health-related needs;

(b) Specified as a related service in the child or young adult’s IEP or IFSP;

(d) A separate school-based health service, other than transportation, specified on the child or young adult’s IEP or IFSP is provided and reimbursed on the same day; and

(e) Supported by a transportation vehicle trip log.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020
DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert ef. 4-1-03
OMAP 31-1998, f. & cert. ef. 9-1-98
HR 21-1995, f. & cert. ef. 12-1-95
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0090 Payment

(1) Payment shall be made for school-based health services in accordance with OARs: 410-120-1340, 943-120-0350, and 410-133-0245.

(2) Evaluation, re-evaluation, and assessment reimbursable time may include:

(a) The time for evaluating and assessing a child or young adult’s school-based health service needs (cannot be delegated);

(b) The time to prepare the written report, including obtaining and interpreting medical information to determine health-related needs or diagnosis or for the purpose of planning treatment.

(3) Care coordination and referral reimbursable time may include:

(a) The time for managing integration of, and access to, Medicaid-covered services for the child or young adult:

(A) With a physician, community practitioner, community organization, the Authority, or the child or young adult’s parent/guardian or coordinated care organization (CCO);

(B) To consult with or provide technical assistance to education agency staff, healthcare providers, or families; and

(b) The portion of a conference between interested parties and an SBHS-recognized provider for developing, reviewing, or revising a treatment plan or to establish, re-establish, or terminate a covered health service.

(4) Direct assistance with selection, acquisition, or use of assistive technology reimbursable time may include:

(a) An assistive technology assessment with one-to-one child or young adult contact time;

(b) The time to prepare the required written report of the need, suitability, and benefits of the use of an assistive technology device or adaptive equipment;

(c) Care coordination and consultation with the child or young adult’s healthcare practitioner, parent/guardian, and the Authority for the acquisition of a personal assistive technology device through the child or young adult’s Medicaid plan; and

(d) Training or technical assistance provided to, or demonstrated with, the child or young adult which may include instructing on the use of an assistive technology device or adaptive equipment in the education setting with professionals (including individuals providing education and rehabilitation services) or the child or young adult’s family members, guardians, advocates, or authorized representative.

(5) Interpreter services may be reimbursed when provided in accordance with OAR 410-120-0001.

(6) Payment for school-based health services is through cost-sharing, a federal financial participation reimbursement that requires a public unit of government to pay the non-federal share pursuant to 42 CFR 433.51.

(a) The education agency is responsible for paying the non-federal share for each payable school-based health service.

(b) The non-federal share is calculated using the Federal Medical Assistance Percentage (FMAP) rates in effect during the quarter when the service is reimbursed.

(c) Public funds may be considered as the state's (non-federal) share in claiming federal financial participation if the public funds:

(A) Are transferred to the state agency from the public unit of government;

(B) Are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds; and

(7) Before reimbursement, the Authority must receive the school medical provider’s corresponding non-federal share payment.

(8) The Authority shall not be financially responsible for payment of any claim or service that the Centers for Medicare and Medicaid Services (CMS) disallows under Medicaid. If the Authority has previously paid the school medical provider any such claim, the school medical provider must reimburse the amount of the claim, less any amount previously paid for the non-federal share portion of that claim, to the Authority.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 4-2004, f. 1-23-04, cert. ef. 2-1-04
OMAP 88-2003(Temp), f. & cert. ef. 12-15-03 thru 5-15-04
OMAP 31-1998, f. & cert. ef. 9-1-98
HR 41-1992, f. 12-31-92, cert. ef. 1-1-93
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0100 School Medical Provider Requirements

The school medical provider is responsible to:

(1) Enroll as a school medical provider with the Authority in compliance with OARs: 410-120-1260 and 943-120-0320.

(2) Ensure school-based health services are provided by SBHS-recognized providers in compliance with School-Based Health Services (SBHS) rules (OARs Division 410, Chapter 133) and OARs 410-120-1260, 410-120-1396, and 410-120-1510.

(3) Document, maintain, and retain credentials and qualifications records for each rendering provider, staff or contractor, providing services in the district in compliance with OAR 410-120-1260. Documentation must state the process by which the school medical provider checked, and periodically re-checked, the Medicaid provider exclusion list to confirm that each rendering provider is eligible to provide health services to Medicaid-enrolled children and young adults.

(4) Confirm each rendering provider, as an employee or under contract with the school medical provider, is eligible to provide Medicaid services. The Authority’s Office of Program Integrity maintains a list of excluded providers on the State Medicaid Fraud Convictions website. The U.S. Department of Health and Human Services’ Office of the Inspector General maintains, with monthly updates, a complete database of individuals and entities currently excluded from Federally funded health care programs.

(5) Ensure rendering providers providing services in education settings document each service in compliance with their respective board rules and OAR 410-120-1360 and OAR 410-133-0320.

(6) Provide for appropriate medical supervision consistent with each rendering provider’s respective scope of practice and board requirements.

(7) Maintain and retain adequate medical and financial records, in compliance with OAR 410-120-1360, necessary to fully disclose the extent of the covered health services provided as part of the child or young adult’s education record.

(8) Document, and submit to the Authority, costs in accordance with OAR 410-133-0245.

(9) Provide access for on-site review of the service-delivery location and education records of Medicaid-enrolled children or young adults if such records are directly related to payments for claims to the school medical provider for Medicaid-covered services. Such information must be provided to any state or federal agency responsible for administration or oversight of the Medicaid program.

(10) Document any changes related to the provision of Medicaid-covered services.

(11) Make certain that services are billed in accordance with OAR 410-120-0035 and SBHS OARs Chapter 410, Division 133.

(12) Comply with all applicable provisions of OARs: Chapter 943, Division 120; Chapter 410, Division 120; and Chapter 410, Division 133.

History

Statutory/Other Authority: ORS 413.042, OAR 410-120-1360, 410-120-1396, 410-120-1510, 943-120-0180, 943-120-0310 & 943-120-1505
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-1998, f. & cert. ef. 9-1-98
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0120 Recognized Providers

(1) School-based health services must be provided and documented by SBHS-recognized providers that provide services within their scope of practice and in compliance with their respective board rules and requirements.

(2) Providers with the following qualifications are recognized by the Authority’s SBHS program to provide Medicaid-covered services in education settings:

(a) A licensed audiologist providing and documenting services within their scope of practice and in compliance with Oregon Board of Examiners for Speech-Language Pathology and Audiology’s OARs Chapter 335;

(b) A licensed psychiatrist providing and documenting services within their scope of practice and in compliance with Oregon’s Medical Practice Act and the Oregon Medical Board’s OARs Chapter 847.

(c) A licensed psychologist providing and documenting services within their scope of practice and in compliance with Board of Psychology’s OARs Chapter 858.

(d) A psychologist associate, practicing under the supervision of a licensed psychologist or with authority to function without immediate supervision, and providing and documenting services within their scope of practice and in compliance with Board of Psychology’s OARs Chapter 858.

(e) A psychology technician, performing allowable services under the supervision of a psychologist, and providing and documenting services within their scope of practice and in compliance with Board of Psychology’s OARs Chapter 858.

(f) A Licensed Professional Counselor (LPC) providing and documenting services within their scope of practice and in compliance with Board of Licensed Professional Counselors and Therapists’ OARs Chapter 833.

(g) A Licensed Professional Counselor Associate (LPCA), performing allowable services under the supervision of an LPC, and providing and documenting services within their scope of practice and in compliance with Board of Licensed Professional Counselors and Therapists’ OARs Chapter 833.

(h) A Licensed Marriage and Family Therapist (LMFT) providing and documenting services within their scope of practice and in compliance with Board of Licensed Professional Counselors and Therapists’ OARs Chapter 833.

(i) A Licensed Marriage and Family Therapist Associate (LMFTA), performing allowable services under the supervision of an LMFT, and providing and documenting services within their scope of practice and in compliance with Board of Licensed Professional Counselors and Therapists’ OARs Chapter 833.

(j) A Licensed Clinical Social Worker (LCSW) providing and documenting services within their scope of practice and in compliance with Board of Licensed Social Workers’ OARs Chapter 877.

(k) A Clinical Social Work Associate (CSWA), holding an unrestricted certificate and practicing under an approved plan of practice and supervision with a LCSW, and providing and documenting services within their scope of practice and in compliance with Board of Licensed Social Workers’ OARs Chapter 877.

(l) A TSPC-licensed School Psychologist providing services within their scope of practice in compliance with OAR Chapter 584, Division 245 and National Association of School Psychologists (NASP) professional standards and documenting services in compliance with NASP professional standards and OAR Chapter 584, Division 245 and OAR 410-120-1360.

(m) A school psychologist intern or practicum student, practicing under the supervision of a TSPC-licensed School Psychologist providing services within their scope of practice in compliance with OAR Chapter 584, Division 245 and NASP professional standards and documenting services in compliance with NASP professional standards and OAR Chapter 584, Division 245 and OAR 410-120-1360.

(n) A TSPC-licensed School Social Worker providing services within their scope of practice in compliance with OAR Chapter 584, Division 245 and National Association of Social Workers (NASW) Practice Standards for School Social Workers and documenting services in compliance with NASW Practice Standards for School Social Workers and OAR Chapter 584, Division 245 and OAR 410-120-1360.

(o) A TSPC-licensed School Counselor providing services within their scope of practice in compliance with OAR Chapter 584, Division 245 and American School Counselor Association (ASCA) standards and documenting services in compliance with ASCA standards and OAR Chapter 584, Division 245 and OAR 410-120-1360.

(p) A licensed dentist providing and documenting services within their scope of practice and in compliance with Oregon Board of Dentistry’s OARs Chapter 818, Oregon Dental Practice Act.

(q) An expanded practice dental hygienist, practicing under the general supervision of a licensed dentist, and providing and documenting services within their scope of practice and in compliance with Oregon Board of Dentistry’s OARs Chapter 818, Oregon Dental Practice Act.

(r) A licensed dental therapist, practicing dental therapy under the supervision of a dentist and pursuant to a collaborative agreement with the dentist, and providing and documenting services within their scope of practice and in compliance with Oregon Board of Dentistry’s OARs Chapter 818, Oregon Dental Practice Act.

(s) A Nurse Practitioner (NP) providing and documenting services within their scope of practice and in compliance with Oregon State Board of Nursing’s OARs Chapter 851, Oregon Nurse Practice Act.

(t) A Registered Nurse (RN) providing and documenting services within their scope of practice and in compliance with Oregon State Board of Nursing’s OARs Chapter 851, Oregon Nurse Practice Act.

(u) A Licensed Practical Nurse (LPN), practicing under the clinical direction of a RN, NP, or physician who meets the standards of licensing or certification for the health service provided, and providing and documenting services within their scope of practice and in compliance with Oregon State Board of Nursing’s OARs Chapter 851, Oregon Nurse Practice Act.

(v) An Unregulated Assistive Person (UAP) performing a specific nursing task that has been delegated to the UAP by a RN or NP. The delegating nurse retains accountability for the nursing procedure and must document services within their scope of practice and in compliance with Oregon State Board of Nursing’s OARs Chapter 851, Oregon Nurse Practice Act.

(w) A licensed dietician providing and documenting services within their scope of practice and in compliance with Oregon Board of Licensed Dieticians’ OARs Chapter 834.

(x) A licensed Occupational Therapist (OT) providing and documenting services within their scope of practice and in compliance with Oregon Occupational Therapy Licensing Board OARs Chapter 339, Occupational Therapy Practice Act.

(y) A Certified Occupational Therapist Assistant (COTA), providing occupational therapy treatment under the supervision of a licensed occupational therapist, and providing and documenting services within their scope of practice and in compliance with Oregon Occupational Therapy Licensing Board OARs Chapter 339, Occupational Therapy Practice Act.

(z) A licensed Physical Therapist (PT) providing and documenting services within their scope of practice and in compliance with Oregon Board of Physical Therapy OARs Chapter 848.

(aa) A licensed Physical Therapist Assistant (PTA), providing physical therapy treatment under the supervision of a licensed physical therapist, and providing and documenting services within their scope of practice and in compliance with Oregon Board of Physical Therapy OARs Chapter 848.

(bb) A Medical Doctor (MD) providing and documenting services within their scope of practice and in compliance with Oregon’s Medical Practice Act and the Oregon Medical Board’s OARs Chapter 847.

(cc) A Doctor of Osteopathic Medicine (DO) providing and documenting services within their scope of practice and in compliance with Oregon’s Medical Practice Act and the Oregon Medical Board’s OARs Chapter 847.

(dd) A Doctor of Podiatric Medicine (DPM) providing and documenting services within their scope of practice and in compliance with Oregon’s Medical Practice Act and the Oregon Medical Board’s OARs Chapter 847.

(ee) A Physician Assistant (PA), practicing under a written collaboration agreement signed by a physician, and providing and documenting services within their scope of practice and in compliance with Oregon’s Medical Practice Act and the Oregon Medical Board’s OARs Chapter 847.

(ff) A licensed Speech-Language Pathologist (SLP) providing and documenting services within their scope of practice and in compliance with Oregon Board of Examiners for Speech-Language Pathology and Audiology’s OARs Chapter 335.

(gg) An educator licensed and endorsed, prior to July 1, 2016, by the Teacher Standards and Practice Commission (TSPC) with a Communication Disorder endorsement (speech language pathology), exempted in ORS 681.230(4) pursuant to SB287, who meets the following requirements:

(A) Holds a Certificate of Clinical Competency (CCC) from the American Speech and Hearing Association (ASHA); or

(B) Has completed the equivalent educational requirements and work experience necessary for the certificate; or

(D) Is authorized to administer speech therapy to an individual when the individual is a child or young adult eligible for special education, as defined by state or federal law, receiving speech therapy services pursuant to an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP).

(hh) A speech-language pathologist in their Clinical Fellowship Year (CFY), practicing under the supervision of a licensed speech-language pathologist, and providing and documenting services within their scope of practice and in compliance with Oregon Board of Examiners for Speech-Language Pathology and Audiology’s OARs Chapter 335.

(ii) A licensed Speech-Language Pathology Assistant (SLPA), practicing under the supervision of a licensed speech-language pathologist, and providing and documenting services within their scope of practice and in compliance with Oregon Board of Examiners for Speech-Language Pathology and Audiology’s OARs Chapter 335.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 17-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert ef. 4-1-03
OMAP 38-1999, f. & cert. ef. 10-1-99
HR 21-1995, f. & cert. ef. 12-1-95
HR 19-1994, f. & cert. ef. 4-1-94
HR 29-1993, f. & cert. ef. 10-1-93
HR 3-1992, f. & cert. ef. 1-2-92
HR 49-1991(Temp), f. & cert. ef. 10-24-91
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0140 Provider Enrollment

(1) Enrollment with the Authority is subject to and in compliance with OAR 410-120-1260 and 943-120-0320.

(2) Education agencies must be enrolled as a school medical provider with the Authority to bill and receive reimbursement for Medicaid-covered.

(3) Supervisory-level rendering providers providing or supervising services in education settings, for which the education agency intends to seek Medicaid reimbursement, must be enrolled with the Authority.

(4) Authority-enrolled providers must submit updates to the Authority within thirty (30) calendar days of the change under the EDMS Coversheet (MSC 3970). Changes include address, contact information, NPI, and Federal Tax Identification Number (TIN), when applicable.

(5) Authority Medicaid provider enrollment process:

(a) For an education agency enrolling as a school medical provider, complete and submit a school medical provider enrollment application including the EDMS Coversheet, all required Oregon Medicaid forms, and the Provider Enrollment Attachment; or

(b) For supervisory-level rendering providers, complete and submit a provider enrollment application including the EDMS Coversheet and all required Oregon Medicaid forms.

(d) The school medical provider may submit completed enrollment forms on behalf of supervisory-level rendering providers that are employed by the school medical provider.

(e) Upon submission of a provider enrollment application, the Authority shall:

(A) Enroll a school medical provider or supervisory-level rendering provider that has satisfied the provider enrollment criteria;

(B) Notify the applicant if information is missing or invalid; or

(D) Upon enrollment, notify the contact listed on the provider enrollment application of the enrolled, assigned Medicaid Identification number.

(6) Revalidation of Authority-enrolled providers is subject to and in compliance with OAR 410-120-1260.

(7) Termination of provider enrollment is subject to and in compliance with OAR 410-120-1260.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-1998, f. & cert. ef. 9-1-98
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0200 Services Not Covered

(1) Oregon’s School-Based Health Services (SBHS) program does not cover or reimburse for:

(a) Services that are not provided and documented by SBHS-recognized providers within their respective scope of practice and in compliance with their respective board rules, OAR 410-120-1360, and OAR 410-133-0120;

(b) Unplanned services in lieu of planned services when an IPOC is required by IDEA, Section 504 of the Rehabilitation Act of 1973, or the provider’s scope of practice;

(d) Meeting preparation;

(e) Report writing as a stand-alone service;

(f) Correspondence (e.g., copying, mailing, etc.);

(g) Purchase of an assistive technology device or software;

(h) Activities related to determining Medicaid eligibility and enrollment status, administrative activities, and travel time by SBHS-recognized providers;

(i) Educational workshops, training classes, and parent training workshops;

(j) Regular transportation services to and from school;

(k) Vocational services;

(l) Services provided to non-Medicaid children or young adults;

(m) Services provided by an entity that employs an excluded provider; or

(n) Planned services performed on a date of service for which the child or young adult’s IPOC has lapsed.

(2) Education-based costs normally incurred to operate a school and provide an education are not covered for Medicaid reimbursement by the Authority.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert. ef. 4-1-03
OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 38-1999, f. & cert. ef. 10-1-99
HR 21-1995, f. & cert. ef. 12-1-95
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0220 Billing

(1) The enrolled school medical provider must:

(a) Bill the Authority in compliance with OARs 410-120-1280 and 943-120-0330;

(b) Bill services using a professional claim format (i.e., paper CMS-1500 or electronic equivalent to the CMS-1500 form).

(c) Include a procedure code, a diagnosis code, a modifier, and a referring provider ID (Medicaid ID or NPI) for each service billed.

(d) Submit timely claims. The Authority shall accept a claim up to 12 months from the date of service. Once a service has been submitted on a claim within the 12-month timely filing limit, the school medical provider has an additional six months to resubmit the denied claim or adjust the paid claim.

(2) Duplicate billing:

(a) Occurs when a claim is submitted for a specific service when the same service is provided and billed for on the same date of service.

(b) Reimbursement made because of duplicate billing shall be recovered.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020
DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert. ef. 4-1-03
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0245 Cost-Based Rates and Payment

(1) The Authority shall determine cost-based rates based upon annual costs submitted by education agencies.

(2) Cost-based rates for each education agency shall:

(a) Be based upon the prior year's annual audited costs and the Oregon Department of Education’s (ODE) approved current year indirect rate.

(b) Establish an hourly rate and a per-minute increment rate for the current calendar year for each covered service discipline (e.g., physical therapy and nursing, as separate disciplines, shall each have a separate rate).

(3) An education agency shall not bill for more than the cost-based rate prescribed by the Authority.

(4) Cost data shall be submitted in a format prescribed by the Authority and in accordance with Oregon's Medicaid State Plan approved by the Centers for Medicare and Medicaid Services (CMS).

(5) Costs for telehealth technologies used to provide school-based health services are included in the cost for each service discipline and are not billed separately.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020
DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05

Or. Admin. R. 410-133-0320 Documentation and Recordkeeping

(1) The school medical provider is responsible for recordkeeping and documentation in adherence to federal, state, and local laws and regulations including OAR 410-120-1360.

(2) Documentation for school-based health services:

(a) Is a combination of education requirements, service documentation by SBHS-recognized providers, and the IPOC, when applicable.

(b) Planned services require an IPOC and service documentation, in adherence to federal, state, and local laws and regulations including OAR 410-120-1360 and OAR 410-133-0320.

(c) Unplanned services require service documentation, in adherence to federal, state, and local laws and regulations including OAR 410-120-1360 and OAR 410-133-0320.

(d) Must include:

(A) Date of service;

(B) Medicaid-enrolled child or young adult’s:

(i) Full name;

(ii) Medicaid ID; and

(iii) Diagnosis code(s);

(D) Name of the rendering provider performing the service;

(E) Name of the healthcare provider supervising the service (when applicable);

(F) Medically necessary and appropriate need for the service;

(G) Location and duration of the service; and

(H) Nature, extent, or units of service.

(3) Service documentation must be documented within the rendering provider’s respective scope of practice and in compliance with their respective board rules and requirements, OAR 410-133-0120, and OAR 410-120-1360.

(4) Recordkeeping for school-based health services provided by SBHS-recognized providers must:

(a) Include information necessary to support each health service billed by the school medical provider including:

(A) If applicable, the child or young adult’s IPOC including any addendum to the IPOC that correlates with the covered health services provided and reimbursed;

(B) If applicable, the Section 504 Accommodation Plan associated with the IPOC; and

(b) Be retained by the school medical provider in compliance with OAR 410-120-1360.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert. ef. 4-1-03
HR 22-1995, f. & cert. ef. 12-1-95
HR 39-1991, f. & cert. ef. 9-16-91

Or. Admin. R. 410-133-0340 Client Rights and Record Confidentiality

(1) School medical providers must provide access to records and documentation that support claims submitted to the Authority for school-based health services provided to Medicaid-enrolled children and young adults when requested by the Authority, Oregon Department of Justice, Medicaid Fraud Unit, Oregon Secretary of State, or the United States Department of Health and Human Services, or their authorized representatives.

(2) Client rights of confidentiality for Medicaid-enrolled children and young adults must be respected in accordance with the provisions of 42 CFR Part 431, Subpart F and ORS 411.320.

(3) School medical providers are subject to the confidentiality laws applicable to student records, including student medical records maintained as part of the education record.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 192.410–192.505
DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00
HR 39-1991, f. & cert. ef. 9-16-91

Division 134 HEALTHIER OREGON

Or. Admin. R. 410-134-0000 Purpose

(1) The purpose of this OAR Chapter 410, division 134 is to set forth the rules that are specific to the Healthier Oregon program.

(2) The Healthier Oregon program is a medical assistance benefit package equal to OHP Plus defined and described in OAR 410-120-1210.

(3) The Healthier Oregon program is funded with state and federal dollars as described in OAR 410-134-0004.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 414.231 & 414.706
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022

Or. Admin. R. 410-134-0001 Acronyms and Definitions

(1) The following acronyms and definitions within this rule specifically apply to the Healthier Oregon program in its entirety.

(a) The Authority incorporates acronyms and definitions in OAR 410-141-3500, OAR 410-120-0000 and OAR 410-200-0015;

(b) The acronyms and definitions adopted by the Department of Human Services (Department) in chapters 411, 413, and 461;

(d) Behavioral Health Division chapter 309 division 19 definitions.

(2) “Citizenship Waived Medical Benefit Package” (CWM) as defined in OAR 410-120-0000.

(3) “Citizenship Waived Medical Plus Benefit Package” (CWX or CWM Plus) as defined in OAR 410-120-0000.

(4) “Emergency Medical Condition” is defined in OAR 410-120-0000.

(5) “Emergency Health Benefit Funding: is defined in OAR 410-120-0000 and in OAR 410-134-0004 of this rule.

(6) “Healthier Oregon Cover All Kids (CAK)” means Cover All Kids as defined in OAR 410-200-0015:

(a) Before July 1, 2022, CAK recipients received state-funded coverage equal to OHP Plus as defined in OAR 410-120-1210.

(b) As of July 1, 2022, recipients are included in Healthier Oregon;

(i) Medical assistance benefit package and coverage is equal to OHP Plus as defined in OAR 410-120-1210; and

(ii) Funding is defined in OAR 410-134-0004.

(7) “Reproductive Health Equity Act (RHEA)” means Reproductive Health Equity Act (ORS 414.432) funding, which provides access to reproductive health and abortion services to Oregonians who are able to get pregnant and who would be eligible for federally funded medical assistance if not for 8 U.S.C. 1611 or 1612.

(8) “Supplemental Health Benefit State Funding” as defined in OAR 410-120-0000 and in OAR 410-134-0004 of this rule.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 413.042, 414.065, ORS 414.025, 414.231, 414.432 & 414.706
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022

Or. Admin. R. 410-134-0003 Healthier Oregon and Healthier Oregon Cover All Kids Coverage

(1) The Healthier Oregon and Healthier Oregon Cover All Kids benefit package description, benefits package identifier, eligibility criteria, and coverage is described in this Rule.

(2) Healthier Oregon and Healthier Oregon Cover All Kids benefit package descriptions:

(a) Benefit Package identifiers:

(A) BMH: for non-pregnant adults 21 and over and Cover All Kids; or

(B) BMP: for pregnant adults or individuals within their post-partum period, who are age 21 and over;

(b) Eligibility criteria: Eligible recipients are individuals who meet the financial and non-financial eligibility requirements for an Health Systems Division (HSD) or Oregon Supplemental Income Program Medical (OSIPM) Program, except they do not meet the citizenship or non-citizen status requirements pursuant to OAR 410-200-0215;

(A) Oregon Health Plan services defined in OAR 410-120-1210;

(B) Oregon Health Plan limitations defined in OAR 410-120-1210.

History

Statutory/Other Authority: ORS 413.042, 414.065 & 414.231
Statutes/Other Implemented: ORS 413.042, 414.065, 414.231, ORS 414.025, 414.312, 414.430, 414.432, 414.706 & 414.710
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022

Or. Admin. R. 410-134-0004 Healthier Oregon Funding

(1) The Healthier Oregon medical assistance benefit package is equal to the medical assistance benefits package defined and describe in OAR 410-120-1210 as OHP Plus but the funding for the benefits is different as set out in this rule.

(2) Emergency Health Benefit Funding includes services that are funded in part with state dollars and matched with federal dollars. Emergency Health Benefit Funding includes:

(a) Services to treat Emergency Medical Conditions as defined by 42 CFR 440.255 and OAR 410-120-0000. The Healthier Oregon Desk Reference, defines claims and limitations for services listed below, that the Oregon Health Authority determines an emergency located at: https://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-CWM.aspx ;

(b) Labor and Delivery;

(d) Outpatient dialysis to treat acute renal failure or End Stage Renal Disease (ESRD);

(e) Immunosuppressant medications post kidney transplant, including office visits and labs to prescribe and monitor such medications;

(f) Cancer treatment;

(g) Dental services provided in an emergency department or hospital setting;

(h) Covid 19 coverage shall be equal to the coverage available during the Federal Public Health Emergency (PHE) and shall end May 11, 2024;

(i) Pregnancy coverage equal to OHP Plus defined in OAR 410-120-1210; subparagraphs (3)(a-m) of this rule are funded by Supplemental Health Benefits State Funding. Pregnancy coverage is partially funded through Children Health Insurance Program (CHIP) as defined in 42 CFR §§ 457.10 and 457.618;

(j) Post-Partum coverage equal to OHP Plus defined in OAR 410-120-1210; subparagraphs (3)(a-m) of this rule set are funded by Supplemental Health Benefits State Funding, beginning the day after pregnancy ends and ending (12) twelve calendar months following the month in which the pregnancy ends. Post-partum coverage is partially funded through CHIP administrative funds as available and reverts to Supplemental Health Benefits State Funding, when CHIP administrative funds are not as available.

(3) Supplemental Health Benefit State Funding includes services that are funded with state funds only. State-Funded Supplemental Health Benefits include:

(a) Abortion services;

(b) Sterilization;

(d) Hospice;

(e) Death with dignity;

(f) Dental services equal to OHP coverage in OAR 410-123-1220;

(g) Post-Partum coverage beginning the day after pregnancy ends and ending (12) twelve calendar months following the month in which the pregnancy ends; if CHIP administrative funds are not available;

(h) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage and limitations defined in OAR 410-151-0000;

(i) Organ Transplants see OAR 410-124-0010;

(j) Pharmacy benefits equal to OHP Plus coverage;

(k) Long-Term Support Services (LTSS) defined in OAR 410-120-0000;

(L) Health Related Social Needs (HRSN) defined in OAR 410-120-0000

(m) OHP Plus coverage and limitations described in OAR 410-120-1210.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 413.042, 414.065, ORS 414.231, 414.312, 414.430, 414.432 & 414.706
DMAP 66-2025, minor correction filed 09/09/2025, effective 09/09/2025
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 13-2023, minor correction filed 03/30/2023, effective 03/30/2023
DMAP 94-2022, amend filed 12/27/2022, effective 01/01/2023
DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022

Or. Admin. R. 410-134-0005 Coverage and Billing for Citizenship Waived Medical and Citizenship Waived Medical Plus

(1) The Citizenship Waived Medical (CWM) and Citizenship Waived Medical Plus (CWM Plus) benefit package ended on June 30, 2023. Prior to July 1, 2023, CWM Plus was referred to as “CWX”.

(2) Benefit and coverage limitations for members who were eligible for, or retroactively determined to be eligible for, the CWM and CWM Plus can be found under DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022.

(3) Citizenship Waived Medical (CWM) and CWM Plus (previously referred to as “CWX”) services delivered on or before June 30, 2023, may be billed if claims are timely submitted in accordance with OAR 410-120-1300. CWM and CWM Plus billing guidance can be found under DMAP 13-2023, minor correction filed 03/30/2023, effective 03/30/2023.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 413.042, 414.065, ORS 414.312, 414.430, 414.432 & 414.706
DMAP 89-2023, adopt filed 12/19/2023, effective 12/20/2023

Division 136 MEDICAL TRANSPORTATION SERVICES

Or. Admin. R. 410-136-3000 Responsibility for Providing Non-emergent Medical Transportation

(1) The Authority shall provide non-emergent medical transportation (NEMT) for eligible clients who receive their Oregon Health Plan (OHP) covered medical services on a fee-for-service basis or are clients enrolled in coordinated care organizations (CCO), and for eligible clients who receive Reproductive Health Access Fund (RHAF) covered services. The Authority shall discontinue providing this service to a client enrolled in a CCO after the date the client is enrolled in a CCO. The CCO shall provide and coordinate the service to their enrollees on and after the date of the client’s enrollment in the CCO pursuant to section (2) of this rule.

(2) When a CCO begins providing NEMT services for its enrollees, the Authority shall provide NEMT services in the CCO’s service area only to clients not enrolled in a CCO:

(a) The Authority may not pay for services covered by a CCO. Reimbursement is a matter between the CCO and its transportation brokerage and subcontractor. Reimbursement is a matter between the CCO and its contracted brokerage and transportation providers;

(b) For clients enrolled in a CCO the transportation provider must coordinate all transportation services with the client’s transportation brokerage or CCO prior to providing services.

(3) The requirements in OAR 410-136-3000–410-136-3360 apply to NEMT services for which the Authority is responsible pursuant to this rule.

(4) Brokerages shall, and must ensure subcontractors, have access to culturally and linguistically appropriate tools available to provide clients accessing NEMT services:

(a) of free written translations, oral interpretation, certified and qualified spoken and sign language interpreters, alternative formats, and auxiliary aids and services, for the client to be able to understand NEMT services information provided;

(b) Alternative formats or languages, including interpretation during phone calls, shall be provided upon request at no cost to the client.

(5) Language access services for NEMT services also applies to client representatives, family members and caregivers with hearing impairments or Limited English Proficiency (LEP) who need to understand the client’s condition and care. For OHP members, see Oregon Health Plan (OHP) program OAR 410-120-0001 Interpreter Services requirements for Medicaid members with Limited English Proficiency services. For RHAF clients, see Certification Requirements for RHCare Clinics Version 3, Certification Requirements for CCare Clinics Version 2, or Certification Requirements for AbortionCare Clinics Version 3 for language access requirements adopted in in OAR 333-004-3030, which are incorporated by reference in this section.

(6) A brokerage may request that the Authority delay responsibility for reimbursement to clients pursuant to OAR 410-136-3240, Client Reimbursed Mileage, Meals and Lodging, until a CCO in the brokerage's service area assumes NEMT services for the CCO's enrolled client. Any delay of responsibility must not exceed fourteen (14) days and must be prior approved by the Authority. The delay of the brokerage's responsibility also includes reimbursing clients in the fee-for-service delivery system.

(7) OAR 410-136-3040, Vehicle Equipment and Subcontractor Standards and OAR 410-136-3120, Secured Transports do not apply to ambulance providers, ambulance vehicles, or ambulance personnel that are licensed and regulated by ORS Chapter 682 and OAR chapter 333, divisions 250, 255, 260 and 265, whether providing ambulance or stretcher transports.

(8) The following definitions specifically apply to OAR 410, division 136. This rule does not include an exhaustive list of Division acronyms and definitions. For more information of any terms not defined in this rule, see Oregon Health Plan (OHP) program OAR 410-141-3500 Acronyms and Definitions; OAR 410-120-0000 Acronyms and Definitions; OAR 309-032-0860; OAR 410-200-0015 General Definitions; and any appropriate governing acronyms and definitions in the Department of Human Services (Department) chapter 411, 413, or 461 administrative rules; or contact the Division. For purposes of the rules OAR 410-136-3000 through 410-136-3360:

(a) “Attendant” means an individual at least 18 years of age to accompany the client. An attendant may also be a behavioral health personal care attendant allowed to accompany the client in accordance with OAR 410-172-0780;

(b) “Brokerage” means a governmental transportation brokerage (local unit of government), or other entity, enrolled by and contracted with the Authority to arrange rides and pay subcontractors for NEMT services;

(c) “Client” means an individual eligible to receive OHP or RHAF health services on the date of service and who resides in the Service Area;

(d) “Contractor” means a transportation brokerage, or other entity, enrolled as an OHP provider by and contracted with the Authority to arrange rides brokerages pay subcontractors for NEMT services;

(e) “Covered service” means medically necessary and appropriate health services and items described in ORS Chapter 414 and applicable administrative rules and the Prioritized List of Health Services above the funding line set by the legislature, consistent with OAR Chapter 410 division 120, or services as described in OAR 333-004-3070;

(f) “Electronic Data Interchange (EDI)” means the exchange of business documents from application to application in a federally mandated format or, if no federal standard has been promulgated, using bulk transmission processes and other formats as the Authority designates for EDI transactions consistent with OAR Chapter 410 division 120;

(g) “Local area” means an area within the accepted community standard and includes the client’s metropolitan area, city, or town of residence;

(h) “Member” means an Oregon Health Plan (OHP) client enrolled with a coordinated care organization (CCO);

(i) “Non-Emergent Medical Transportation Services (NEMT)” means transportation to or from a source of covered service, that does not involve a sudden, unexpected occurrence which creates a medical crisis requiring emergency medical services as defined in OAR 410-120-0000 and requiring immediate transportation to a site, usually a hospital, where appropriate emergency medical care is available;

(j) “Provider” means a public Agency, non-profit company, for-profit company, or an individual with whom a brokerage subcontracts with to provide rides;

(k) “RHAF” means Reproductive Health Access Fund, a source of coverage for reproductive health services as defined in OAR 333-004-3070 provided to individuals who complete the RH Access Fund Enrollment Form and are deemed eligible (“RHAF client”).

(L) "RH Access Fund Eligibility Database" means the centralized, web-based data system operated by the RH Program to house information about enrollees.

(m) “Ride” means to drive the client to and from Oregon Health Plan (OHP) covered services or RHAF covered services;

(n) “Secure transport” means NEMT services for the involuntary transport of clients who are in danger of harming themselves or other individuals;

(o) “Service area” means the geographic area within which the Regional Brokerage agreed under contract with the Authority to provide Rides as a service through the contractor’s Call Center;

(p) “Subcontractor” means the provider, individual or entity, with which the brokerage executes a contract to drive the client to and from Oregon Health Plan (OHP) covered services;

(q) “The Authority” means the Oregon Health Authority (OHA);

(r) "Volunteer" (for the purposes of NEMT) means an individual selected, trained and under the supervision of the ODHS who is providing services on behalf of the ODHS in a non-paid capacity except for incidental expense reimbursement under the ODHS Volunteer Program authorized by ORS 409.360.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 29-2014, f. & cert. ef. 5-20-14
DMAP 69-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3010 Coordinated Care Organizations

(1) The Authority contracts with Coordinated Care Organizations (CCOs) to provide medical services for clients receiving Title XIX and Title XXI services for the purpose of providing integrated and coordinated care services across physical health, dental health, and non-emergent medical transportation (NEMT). OAR chapter 410, division 120 including OAR 410-120-1210 describes services through CCOs and division 141 including OAR 410-141-3920 through OAR 410-141-3965 describes NEMT requirements through CCOs.

(2) For clients enrolled in a CCO, NEMT services are included in the budget provided to a CCO by the Authority. The CCO shall provide NEMT services to its enrolled members.

(3) For clients enrolled in a CCO, all transportation services must be coordinated through the member’s CCO or the CCO’s designated transportation provider prior to receiving services.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 39-2014, f. & cert. ef. 7-1-14

Or. Admin. R. 410-136-3020 General Requirements for NEMT

(1) The Authority may enroll governmental transportation brokerages (local units of government) or other entities contracted with the Authority as a “contractor” to arrange rides. Transportation brokerages pay subcontractors for NEMT services. The Authority may limit the enrollment with transportation brokerages to units of local government; Transportation brokerages shall be enrolled as an Oregon Health Plan (OHP) provider and meet all requirements of OAR 410-120-1260 prior to delivering NEMT services or receiving payment. A governmental transportation brokerage signing the Provider Enrollment Agreement constitute agreement to comply with all applicable Authority OHP provider rules and federal and state laws and regulations.

(2) The actions described in this rule may not be delegated and must be performed by the brokerage contracted with the Authority. The brokerage shall:

(a) Prior authorize and pay subcontractors for the least costly but most appropriate mode of transport for the client’s medical needs to and from an OHP covered medical service. The most appropriate and least costly ride may include requiring the client to share the ride with other clients. RHAF clients must not be required to share a ride with other clients;

(b) Verify that the client is obtaining OHP covered medical services in the client’s local area;

(c) Verify the client’s OHP or RHAF eligibility and that the client’s benefit package includes NEMT services on the scheduled date of service for the requested transport. The brokerage shall verify OHP eligibility and benefits packages through electronic eligibility information with the Authority Electronic Data Interchange (EDI). The brokerage shall verify RHAF eligibility through the RHAF eligibility database;

(d) Assess the client’s access to other means of transportation, such as driving their own car or getting a ride from a friend, family member or neighbor;

(e) Verify the client’s attendance for continuing requests for rides if the medical provider could not affirm an appointment for a previous ride;

(f) Schedule a ride with an alternate subcontractor if the subcontractor originally assigned is unable to provide the ride; and

(g) Assign rides to the subcontractor based on an evaluation of several factors including, but not limited to:

(A) Cost;

(B) The client’s need for appropriate equipment and transportation;

(D) Any factors related to the brokerage’s need to maintain sufficient service capacity to meet client needs.

(4) Pursuant to OAR 410-120-1210, Medical Assistance Benefit Packages and Delivery System, clients receiving the Qualified Medicare Beneficiary (QMB) only benefit package are not eligible for NEMT.

(5) The brokerage shall maintain records of prior authorization approval and denials of NEMT services. The brokerage shall also include the reasons for authorizing a ride:

(a) That is not cost effective or not based on the factors specified in section (2) of this rule;

(b) With more than two (2) attendants for an ambulance or stretcher car; or

(6) The brokerage shall provide a ride to a client to fill prescription medication only in the following situation:

(a) The client needs to stop on the way home to fill or pick up prescribed medication related to the covered service for which the brokerage provided the ride;

(b) It is medically necessary to fill or pick up the medication immediately; and

(7) The brokerage may provide a ride to a client to fill prescribed medication under the following situations:

(a) The brokerage asks the client if the prescription service is available through the Authority’s contracted postal prescription service, and the client responds that it is not available through that source;

(b) The client has an urgent need to fill or pick up prescribed medication because the postal prescription service mailed the wrong medication, or the client has an unexpected problem caused by the medication; or

(c) The client is transient or without regular access to a mailbox. In this situation, the brokerage may evaluate the need on a case-by-case basis.

(8) The brokerage shall provide rides outside the brokerage’s local service area as described in section (2)(b) of this rule, under the following circumstances:

(a) The client is receiving a covered service that is not available in the service or local area but is available in another area of the state;

(b) The client is receiving a covered service in California, Idaho, or Washington where the service location is no more than 75 miles from the Oregon border; or

(d) For RHAF clients, no local medical provider will provide the covered services within the timeline required to address the client’s medical condition.

(9) Brokerages may coordinate to provide a return ride to a client who receives a covered service outside the client's local area.

(10) Brokerages shall retroactively authorize and pay for NEMT services that have already occurred only when the brokerage could not prior authorize the service because the brokerage was closed, and the request for authorization is received by the brokerage within thirty (30) days of the date of service. The brokerage shall confirm with the medical provider that one of the following circumstances supported the ride:

(a) The client needed urgent medical care;

(b) The client required secured transport pursuant to OAR 410-136-3120, Secured Transports; or

(11) In addition to section (10) of this rule, a brokerage shall retroactively authorize NEMT services for ambulance transports when:

(a) An ambulance provider responds to an emergency call, but the client’s medical condition does not warrant an emergency transport;

(b) The ambulance provider transports the client as a NEMT service; and

(12) Brokerages shall not authorize or pay subcontracted providers for rides outside their service areas based only on client preference or convenience.

(13) Brokerages shall provide toll-free call centers for clients to request rides. Brokerages shall have written policies and procedures regarding its NEMT services that include all the requirements in this rule. Brokerages shall meet all the following requirements pertaining to the brokerage’s call center and scheduling of rides:

(a) The call center shall operate at a minimum Monday through Friday from 9:00 a.m. to 5:00 p.m., but the brokerage may close the call center on New Year’s Day, Memorial Day, July 4th, Labor Day, Thanksgiving, and Christmas. The Authority may approve, in writing, additional days of closure if the brokerage requests the closure at least thirty (30) days in advance.

(b) Brokerages shall make all reasonable efforts for clients to have access to available NEMT services 24 hours a day. When the call center is closed, the brokerages shall provide a recording or answering service in at a minimum, English and Spanish, to refer the client directly to a subcontractor. If no subcontractor is available, the brokerage must provide clients with recorded information in at a minimum, English and Spanish, about service hours and how to reach emergency services by calling 911;

(c) The brokerage shall allow a client or their representative to schedule rides at least ninety (90) days in advance of the covered service;

(d) The brokerage shall allow a client or their representative to request multiple ride requests at one time;

(e) The brokerage shall develop and make all policies and procedures regarding its NEMT services available to clients either in a OHP Open Card Member Handbook, RHAF NEMT Rider Guide, or in a stand-alone document referred to as a “OHP Open Card NEMT rider guide” that meets the delivery and content specifications defined by the Authority. The brokerage’s written policies and procedures regarding NEMT services must be shared to subcontractors and shall be available upon request to the Authority for review.

(f) Allow a client or their representative, including providers in accordance with OAR 410-172-0780, to schedule:

(A) NEMT services up to ninety (90) days in advance;

(B) Multiple NEMT services at one time for recurring appointments up to ninety (90) days in advance; and

(g) Comply with the following criteria for client drop-offs and pick-up protocols. A brokerage or subcontractors’ drivers are not permitted to:

(A) Drop off a client at an appointment more than 15 minutes prior to the office or other facility opening for business unless requested by the client or, as applicable, the client’s guardian, parent, or representative; and

(B) Pick up a client from an appointment more than 15 minutes after the office or facility closes for business unless the appointment is not reasonably expected to end within 15 minutes after closing, or as requested by the client, or as applicable, the client’s guardian, parent, or representative.

(h) The brokerage shall provide to the client, or as applicable, the client’s guardian, parent, or representative the name of subcontractor, or name and telephone number of the driver when available;

(i) The brokerage shall confirm the scheduled pick-up time and address with the client;

(j) The brokerage shall make reasonable efforts to arrange a ride requested on the day of the medical service when the service is:

(A) For an urgent medical condition; and

(B) Due to the urgency of the medical condition, the client scheduled an immediate medical appointment.

(14) The brokerage is not responsible for providing emergency medical transportation services. However, brokerages shall have procedures for referring clients requesting emergency medical transportation services to the appropriate emergency transportation resources and procedures for subcontractors per OAR 410-136-3040, Vehicle Equipment and Subcontractor Standards.

(15) The Authority shall collaborate with brokerages and CCOs to develop and conduct a statewide client NEMT satisfaction survey at least once every two years. The Authority may contract with one or more brokerages, or a third party, to conduct the survey. The Authority shall use the results of the survey to identify and address potential operational deficiencies and to identify and share successes in the NEMT program.

(16) Brokerages shall establish regional advisory groups consisting of representatives from the Authority, ODHS, Area Agencies on Aging, consumers, representatives of client advocacy groups from within the service or local area, brokerage subcontractors, and providers of NEMT ambulance services. The role of the group includes, but is not limited to:

(a) Assisting in monitoring and evaluating the NEMT program; and

(b) Recommending potential policy or procedure changes and program improvements to brokerages and the Authority and assisting in prioritizing those changes and improvements.

(17) Brokerages shall have the discretion to use or not use Oregon Department of Human Services (ODHS)-approved volunteers. ODHS shall provide brokerages with a list of approved and trained volunteers. ODHS shall supervise the volunteers and assumes all liability for each volunteer as provided by law.

(18) Brokerages or their subcontractors shall not bill eligible client for any NEMT service to and from a covered service or any transports where the Authority denies reimbursement. Brokerages or their subcontractors shall not collect payment from the client, or assign an unpaid claim to a collection agency, or similar entity pursuant to ORS 414.066.

(19) On a minimum of five percent of the ride requests, brokerages shall contact medical providers to verify appointments and that the appointments are for covered medical services.

(20) Brokerages may purchase tickets for common carrier transportation, such as inter- or intra-city bus, train, or commercial airline when deemed cost effective and safe for the client.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 96-2024, temporary amend filed 05/31/2024, effective 06/01/2024 through 11/27/2024
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 20-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 29-2014, f. & cert. ef. 5-20-14
DMAP 69-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3040 Vehicle Equipment and Subcontractor Standards

(1) Brokerages shall require all subcontractors, providers, and drivers to maintain their vehicles for the comfort and safety of the clients. The vehicles shall meet the following requirements:

(a) The interior of the vehicle shall be clean;

(b) The subcontractor, provider, or driver shall not smoke, aerosolize or vaporize an inhalant or permit smoking, aerosolizing or vaporizing of an inhalant in the vehicle at any time; and

(c) The subcontractor, provider, or driver shall comply with appropriate local, state, and federal transportation safety standards regarding passenger safety and comfort. The vehicle shall include, but is not limited to, the following safety equipment:

(A) Safety belts for all passengers if the vehicle is legally required to provide safety belts;

(B) A first aid kit;

(D) Roadside reflective or warning devices;

(E) A flashlight;

(F) Tire traction devices when appropriate;

(G) Disposable gloves; and

(H) All equipment necessary to transport clients using wheelchairs or stretchers in accordance with the Americans with Disabilities Act of 1990 (as amended) (ADA), Section 504 of the Rehabilitation Act of 1973, and Oregon Revised Statute 659A.103 if the subcontractor, provider, or driver uses the vehicle for these modes of transport.

(2) The subcontractor, provider, and driver shall follow a preventative maintenance schedule that incorporates at least all the maintenance recommended by the vehicle manufacturer. The vehicle must be in good operating condition and shall include, but is not limited to:

(a) Side and rear view mirrors;

(b) Working horn;

(d) Working headlights:

(e) Working taillights; and

(f) Working windshield wipers.

(3) Brokerages and subcontractors shall have and maintain records of inspection and compliance with the safety equipment and preventative maintenance requirements in (1) and (2) of this rule. All records shall be made available upon request for audit or review.

(4) Brokerages shall require the subcontractors, providers, call-center employees, and drivers receive and successfully complete training on their job duties, roles, and responsibilities, including but not limited to:

(a) Understanding NEMT services in general, reporting forms, vehicle operation, requirements for reporting of suspected fraud, abuse, or waste by any provider or client and the protections afforded to those who report FWA under applicable whistleblower laws in section 1902(a)(68) of the Social Security Act, and the geographic area in which subcontractors will provide service. Training shall be completed at the time of hire or contracting and at least annually;

(b) Requiring the subcontractors’ drivers to complete the National Safety Council Defensive Driving course or an equivalent course within six (6) months of the date of hire and at least every three (3) years thereafter;

(c) Requiring the subcontractors’ drivers to complete Red Cross-approved First Aid, Cardiopulmonary Resuscitation and blood spill procedures courses or equivalent courses within six (6) months of the date of hire and to maintain the certification as a condition of employment;

(d) Requiring the subcontractors’ drivers to complete the Passenger Service and Safety course or an equivalent course within six (6) months of the date of hire and at least every three (3) years after that;

(e) Understanding established procedures for subcontractors and the subcontractors’ drivers in the event that the client needs emergency care during the ride; and

(f) If providing ground or air ambulance services, verifying that the Authority has licensed the subcontractor to operate ground or air ambulance. If the subcontractor is located in a contiguous state and regularly provides rides to OHP or RHAF eligible clients, the brokerage must ensure that both the Authority and the contiguous state have licensed the subcontractor.

(5) Brokerages shall require a subcontractor meet all the requirements of the chapter 410 division 136 rules at all times to be eligible to receive payment, including but not limited to the following for each of subcontractors’ drivers:

(a) The subcontractor shall require each driver have a valid Oregon DMV-issued drivers license. Brokerages and subcontractors shall require drivers have current license and registration prior to providing an NEMT service. The driver’s license must be the class of license, with any required endorsements, that permits the subcontractor’s driver to legally operate the vehicle for which they are hired to drive per ORS Chapter 807 and OAR chapter 735, division 062, or the applicable statutes of other states; and

(b) The subcontractors’ drivers whether directly employed by the subcontractor or under contract must pass a criminal background check in accordance with ORS 181A.195 and OAR chapter 257, division 10, at the time of hire or contracting or if the brokerage is a mass transit district formed under ORS chapter 267, the subcontractor’s drivers must pass a criminal background check in accordance with ORS 267.237 and the mass transit district’s background check policies. The brokerage or subcontractor must maintain records of background check results for each driver and may perform a background check at any time while the driver is employed or contracted. A driver who does not successfully pass a background check is not eligible to provide rides or receive payment by the brokerage or subcontractor.

(6) For authorized out-of-state NEMT services described in OAR 410-136-3080, in which the subcontractor solely performs work in the other state and for which the brokerage has no oversight authority, the brokerage is not responsible for requiring that the subcontractor’s vehicle and the subcontractor’s standards meet the requirements set forth in this rule.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 87-2015, f. 12-29-15, cert. ef 1-1-16
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3060 Insurance Requirements

(1) Brokerages must obtain and maintain general and automobile liability coverage for personal injury and death in accordance with ORS 30.271, Limitations on Liability of State for Personal Injury and Death.

(2) Brokerages must obtain and maintain general and automobile liability coverage for property damage and destruction in accordance with ORS 30.273, Limitations on Liability of Public Bodies for Property Damage or Destruction.

(3) The liability coverage required by sections (1) and (2) of this rule shall include the State of Oregon, the Authority and its divisions, officers, employees, and agents as additional insureds but only as related to the brokerages’ NEMT services.

(4) In lieu of purchasing liability coverage under sections (1) and (2) of this rule, the Authority may authorize a brokerage to establish and maintain a Self-Insurance Reserve Fund. The following apply to requirements of the fund:

(a) The Authority shall establish the fund at $1 million through the fixed rate for rides established in OAR 410-136-3200, Reimbursement and Accounting for all Modes of Transport;

(b) The fund shall comply with Federal Acquisition Regulation (FAR) Office of Management and Budget (OMB) Circular 87;

(c) If the brokerage subsequently terminates its enrollment with the state as a Medicaid provider, the brokerage shall refund the Authority the balance of any monies in the fund within two (2) years from the termination of its enrollment or at the conclusion of any claim or litigation related to the brokerage’s NEMT services for eligible clients;

(d) Once funded, the fund shall be maintained at an amount not less than $1 million through the fixed rate for rides established in OAR 410-136-3200, Reimbursement and Accounting for all Modes of Transport;

(e) The Authority shall reconcile the fund amount during the annual cost settlement process pursuant to OAR 410-136-3200, Reimbursement and Accounting for all Modes of Transport, and shall increase or decrease the fixed rate for rides to maintain the $1 million fund amount; and

(f) The brokerage shall maintain a separate account for the fund.

(5) Brokerages and their subcontractors that employ workers as defined in ORS 656.027 shall comply with 656.017 and shall provide workers’ compensation insurance coverage for those workers unless they meet the requirement for an exemption under 656.126(2). Brokerages shall require each of their subcontractors to comply with this requirement.

(6) In lieu of purchasing workers’ compensation insurance coverage as required by section (5), a brokerage may self-insure for all its subject workers. The Authority shall not fund this reserve and shall only reimburse the brokerage for costs of self-insurance in the event of a claim arising from the brokerage’s NEMT services to eligible clients.

(7) Brokerages and their subcontractors shall furnish proof of liability coverage and insurance to the Authority upon request.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 29-2014, f. & cert. ef. 5-20-14
DMAP 69-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3080 Out-of-State Transportation

(1) “Out-of-state transportation” means transportation to or from any location outside Oregon, with the exception of contiguous areas up to 75 miles outside the Oregon border.

(2) The brokerage shall arrange rides and pay for out-of-state transportation, as defined in section (1) of this rule, to and from an out-of-state OHP or RHAF covered medical service when:

(a) The brokerage confirms that the Authority authorized the OHP client’s out-of-state OHP covered medical service per OAR 410-120-1180, Medical Assistance Benefits: Out-of-State Services or the CCO authorized per OAR 410-141-3930 Transportation: Out-of-Service Area and Out-of-State Transportation; and

(b) The client is eligible for transportation services per OAR 410-136-3020, General Requirements for NEMT.

(3) The brokerage shall arrange for and pay for the most appropriate mode of transportation, and necessary travel to and from an airport or other departure location within Oregon, for out-of-state travel approved by the Authority.

(4) The brokerage may utilize any procurement method and criteria to purchase airline tickets, and any necessary travel to and from an airport or other departure location within Oregon, subject only to least expensive mode of transportation that meets the non-emergent medical needs of the client.

(5) Brokerages shall not arrange or pay for:

(a) A client’s return from any foreign country to any location within the United States for the client to obtain medical care because the care is not available in the foreign country;

(b) A client’s return to Oregon from another state when the client was not in the other state to obtain authorized medical services or treatments, unless the client is enrolled in RHAF, lives outside of Oregon, and is seeking RHAF covered services within Oregon.

(6) Brokerages may arrange emergency medical transportation services if authorized by the Authority, for a client traveling outside Oregon for a OHP covered medical service who experience an emergency medical condition needing emergency medical transportation as defined in OAR 410-120-0000.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3100 Attendants for Child Transports

(1) This rule applies to non-emergent medical transportation (NEMT) for children twelve (12) years of age and under who are eligible for NEMT services to and from Oregon Health Plan (OHP) and RHAF covered medical services. The rule also applies to children and young adults with special physical or developmental needs, regardless of age, hereafter referred to as “child” or “children.”

(2) Parents or legal guardians must provide an attendant to accompany the children while traveling to and from medical appointments except when:

(a) The driver is a DHS volunteer, DHS employee or an Authority employee;

(b) The child requires secured transport per OAR 410-136-3120, Secured Transports;

(c) An ambulance subcontractor transports the child for NEMT services, and the brokerage reimburses the ambulance subcontractor at the ambulance transport rate; or

(d) The child is enrolled in RHAF and seeking RHAF covered services.

(3) Attendants are required for NEMT ambulance transports when the brokerage uses an ambulance to provide wheelchair or stretcher car or van rides.

(4) ODHS shall establish and administer written guidelines for children in the department’s custody, including written guidelines for volunteer drivers. If ODHS’s requirements or administrative rules differ from this rule, ODHS’s requirements or administrative rules take precedence.

(5) An attendant may be the mother, father, stepmother, stepfather, grandparent or legal guardian of the child. The attendant also may be any adult that the parent or legal guardian authorizes to be an attendant. An attendant also may be a brother, sister, stepbrother or stepsister of the child, as long as the attendant is at least eighteen (18) years of age, and the parent or legal guardian authorizes it. An attendant also may be a behavioral health personal care attendant allowed to accompany the client in accordance with OAR 410-172-0780.

(6) Brokerages or their subcontractors may require the child’s parent or legal guardian to provide written authorization for an attendant other than themselves to accompany the child.

(7) Brokerages or their subcontractors shall not bill additional charges for a child’s attendant.

(8) The attendant must accompany the child from the pick-up location to the destination and on the return trip. The attendant must also remain with the child during their appointment. Another person shall not accompany the attendant unless the parent or legal guardian authorizes it or unless the other person is an eligible child traveling to the same location for a medical appointment.

(9) The parent, guardian or adult caregiver for the child shall provide and install child safety seats as required by state law. The subcontractor shall not transport a child if a parent or legal guardian fails to provide a child safety seat that complies with state law.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3120 Secured Transports

(1) Secured transport NEMT services are for the involuntary transport of clients who are in danger of harming themselves or other individuals. Secured transports are allowable when:

(a) The brokerage verified that the subcontractor has met the requirements of the secured transport protocol pursuant to OAR 309-033-0200 through 309-033-0970, and, therefore, the subcontractor is able to transport the client who is in crisis or at immediate risk of harming themselves or others due to mental or emotional problems or substance abuse; and

(b) The transport is to a Medicaid enrolled facility that the Authority recognizes as being able to treat the immediate medical or behavioral health care needs of the client in crisis.

(2) One additional attendant may accompany the client at no additional charge when medically appropriate, such as to administer medications, etc. in-route, or to satisfy legal requirements, including, but not limited to when a parent, legal guardian or escort is required during transport.

(3) The brokerage shall authorize transports to and from OHP covered medical services for an eligible client when the court orders the medical service with the following exceptions:

(a) The client is in the custody of or under the legal jurisdiction of any law enforcement agency;

(b) The client is an inmate of a public institution as defined in OAR 461-135-0950, Eligibility for Inmates; or

(4) The brokerage shall assume that a client returning to their place of residence is no longer in crisis or at immediate risk of harming themselves or others, and is, therefore, able to use non-secured transportation. In the event that a secured transport is medically appropriate to return a client to their place of residence, the brokerage shall obtain written documentation, signed by the treating medical professional, stating the circumstances that required secured transport. The brokerage shall retain the documentation and a copy of the order in their record for the Authority to review.

(5) The brokerage shall not approve or pay for secured medical transport provided to a person going to or from a court hearing or to or from a commitment hearing.

(6) The Authority is not a law enforcement agency as defined in OAR 461-135-0950 in accordance with ORS 131.930, and as stated in OAR 461-135-0950(2)(a)(A) for an inmate living in a public institution awaiting trial or an individual serving a sentence for a criminal offense. If an NEMT eligible client is not in criminal custody as an inmate under the jurisdiction of a law enforcement agency, then transport from a penal or detention facility to a Medicaid enrolled facility for an OHP covered service is authorized.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3140 Transports of Clients Changing Hospitals or Other Facilities

(1) Brokerages shall arrange and pay for transporting an eligible client who has had a change in condition, noted in the client’s Oregon Department of Human Services (ODHS) care plan, resulting in a need for a new service setting with a lower or higher level of care. This includes clients who are changing levels of care between their community-based care settings or between institutional and community-based settings. The client’s ODHS worker must request the ride.

(2) Brokerages shall not arrange or pay for:

(a) The transport or return of an inpatient client from an admitting hospital to another hospital (or facility) for diagnostic or other short-term services when the patient will return to the admitting hospital within the first 24-hours of admission. The subcontractor shall bill the admitting hospital directly for these transports;

(b) The transport of a client receiving long-term care service in their home or residing in a long-term care facility for the sole purpose of shopping for another long-term care facility, even if the client is looking for a new facility to receive a lower or higher level of care;

(c) The transport of a client moving from one type of facility to a facility of the same type, such as from an adult foster home to another adult foster home; and

(d) The transport of a client who is relocating to another state, unless the transport is to receive an OHP covered medical service pursuant to OAR 410-136-3080, Out-of-State Transportation.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 29-2014, f. & cert. ef. 5-20-14
DMAP 69-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3160 Ground and Air Ambulance Transports

(1) Transporting a client via ambulance is required when a medical facility or provider states the client’s medical condition requires the presence of a health care professional during the emergency or non-emergency transport. This includes neonatal transports.

(2) For non-emergent medical transportation (NEMT) services, the brokerage shall authorize the transport.

(3) Brokerages shall provide ambulance or stretcher transports with a medical technician when:

(a) A client’s medical condition requires a stretcher;

(b) The length of transport would require a personal care attendant; and

(4) Emergency ambulance transportation is required when a client’s medical condition is an emergency pursuant to OAR 410-120-0000, Acronyms and Definitions. The ambulance must transport the client to the nearest appropriate facility able to meet the client's medical needs. Brokerages do not arrange emergency transportation.

(5) The following apply to air-ambulance NEMT services:

(a) The brokerage shall approve air-ambulance NEMT only when another mode of transportation would further jeopardize or compromise the client's medical condition due to:

(A) The length of time required to transport the client by ground-ambulance;

(B) Current road conditions preclude the use of ground transportation; or

(b) As an exception to section (4) (a) of this rule, the brokerage may grant air-ambulance transportation if it determines the transportation is cost effective. The brokerage shall document how air-ambulance is more cost effective than ground transportation;

(c) The brokerage must obtain a written recommendation from the client’s medical provider indicating medical appropriateness before authorizing air-ambulance transportation.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3180 Reimbursement for Ground and Air Ambulance Transports

(1) The following applies to how the Oregon Health Authority (Authority) shall reimburse providers of NEMT ground and air ambulance services that brokerages arrange for eligible clients. This applies to clients receiving services through the fee-for-service (FFS) delivery system or a Coordinated Care Organization (CCO).

(2) FFS brokerages shall submit documentation to the Authority stating the brokerage authorized the transportation. The documentation also shall inform the Authority to reimburse at the Authority’s base rate or another amount the brokerage specifies. Ambulance providers shall bill the Authority for payment of authorized rides.

(3) If brokerage does not specify another amount, the Authority’s reimbursement shall include:

(a) The base rate established in the Authority’s fee schedule posted on the OHP Web page at www.oregon.gov/OHA/HSD/OHP/Pages/Fee-Schedule.aspx.

(A) The base rate for NEMT ground ambulances includes:

(i) Any procedures or services provided, all medications, non-reusable supplies or oxygen and all direct or indirect costs. “Indirect costs” include general operating costs, personnel costs, neonatal intensive care teams employed by the ambulance subcontractor, use of reusable equipment and any other miscellaneous medical items or special handling that may be required in the course of transport;

(ii) The first ten miles for ground ambulance transports.

(B) The base rate for NEMT air ambulances includes:

(ii) different rates shall apply for urban and rural using the statewide average adjustments for the geographic regions of Oregon at a percent of Medicare. This methodology includes the mileage rate reimbursed separately instead of included into the base rate. The urban and rural rates are defined by Zip Code-Point of Pick Up.

(b) A modified base rate for each additional client, according to OAR 410-136-3220, Brokerage Reimbursements to Subcontractors, if applicable;

(d) Compensation for service or care provided at the scene when the client did not require transport, if applicable.

(4) Reimbursement outlined in section (3) of this rule also applies to the Authority’s reimbursements to providers of emergency ground or air ambulance services for clients who receive services through the fee-for-service delivery system.

(5) A CCO is responsible for reimbursement to providers of emergency ground or air ambulance for clients who are CCO enrollees.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 117-2024, amend filed 08/19/2024, effective 08/19/2024
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 53-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3200 Reimbursement and Accounting for all Modes of Transports

(1) The following applies to the rate the Oregon Health Authority (Authority) pays brokerages:

(a) The Authority shall calculate and pay a brokerage a fixed rate for rides based on the following formula: Direct costs plus indirect costs divided by the number of projected monthly rides. “Direct costs” are transportation costs plus administrative costs;

(b) The Authority shall notify the brokerages of their specific ride rates; and

(A) Quarterly;

(B) When the Authority changes any program affecting eligibility or scope; or

(2) Brokerages shall account for costs and expenses of non-emergent medical transportation (NEMT) services to Oregon Health Plan (OHP) Fee For Service (FFS) clients and RHAF clients separate from any other services the brokerage provides. Brokerages shall require all subcontractors to account for costs and expense for NEMT services separate from any other services the subcontractors provide. Brokerages shall use and require all subcontractors to adopt generally accepted accounting principles or accounting standards or cost principles required by federal or state laws, rules, or regulations.

(3) The Authority shall reimburse brokerages for valid claims submitted to the Authority, using the standardized electronic billing format prescribed by the Authority for OHP clients and the specified billing format prescribed by the Authority for RHAF clients. All brokerages’ professional claims for transportation services shall include a HIPAA-compliant, the Centers for Medicare and Medicaid Services (CMS)-defined 2- digit POS code to indicate the type of transportation service used and have the required combination of modifier and procedure code. All required billing information must be included on the claim for the additional client. Medicaid is always the payer of last resort. If a client has Medicare or third-party insurance, the brokerages shall bill these insurers before billing the Authority.

(4) The Authority shall conduct an annual cost settlement to review brokerages costs and expenses and determine any overpayment or underpayment for costs the brokerage incurred for covered NEMT services for eligible clients. The following applies to the Authority’s cost settlement process:

(a) The Authority shall request cost and expense settlement information from the brokerages 6 months after the end of the fiscal year. The request shall include file(s) detailing the brokerages claims, a template for the brokerages to submit their cost and expenses information and instructions for completing the template. The Authority uses the Oregon Medicaid Management Information System (MMIS) to create file(s) detailing the brokerages claims data for the applicable procedure codes per NEMT provider;

(b) Brokerages shall submit the requested information, certified by a Certified Public Accountant, and complete the template provided by the Authority within 90 days of receiving the Authority’s request;

(c) The Authority shall verify the reported costs and expenses and notify the brokerages in writing of the Authority’s determination;

(d) Brokerages shall comply with the allowable cost requirements established by the Authority;

(e) If the Authority’s determination results in an adjustment, the brokerages may request an appeal pursuant to OAR 410-120-1560 through 410-120-1600, pertaining to provider appeals.

(f) The brokerage shall refund the amount of the overpayment determined by the Authority within sixty (60) days or as specified by the Authority in its written notice to the brokerage.

(g) Payment by the Authority does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit before or after the payment is made to a brokerage. Payments may be denied or subject to recovery by the Authority if medical review, audit, or other post-payment review of the supplemental payment or the claim upon the basis a supplemental payment was issued determines the service was not provided in accordance with applicable rules, by an eligible NEMT provider, or does not meet the criteria for quality of care or medical appropriateness of the care or payment.

(5) To be eligible for payment brokerages and subcontractors must meet all of the requirements in chapter 410 division 136 rules and chapter 410 division 120 rules. The Authority shall pay for covered services the brokerage authorized and provided in good faith, including mailing transit passes to clients. The Authority shall use the rate in effect on the day of the transport or the mailing date of the transit passes. For the purpose of this rule “Good faith” means:

(a) The brokerage verified client eligibility on the date of service or the date of mailing the transit passes, using the Authority’s eligibility information; or

(b) The client eligibility information was inconsistent or not available, and the brokerage used the most recent client information available immediately before the time of service or mailing of transit passes.

(6) Each brokerage may establish a working capital reserve with funds the Authority provides. The following applies to any established working capital reserve:

(a) The working capital reserve shall represent thirty (30) days of cash expenses for normal operating purposes. The Authority may base the reserve on a time other than thirty (30) days if circumstances warrant the change;

(b) The Authority shall calculate the reserve amount as part of the annual cost settlement for the most recent past fiscal year;

(c) The Authority shall base the reserve amount on an average of six (6) months of operating expenses that the brokerage reports in its monthly NEMT financial reports. However, the Authority may base the reserve amount on more or less than six (6) months of expenses when a six-month average does not reflect an accurate accounting of expenses;

(d) Brokerages shall maintain a separate account for the reserve funds; and

(e) The Authority may require the brokerage to return any funds in excess of the amount the Authority calculated, or the Authority may decrease the ride rate to reduce the reserves. If the Authority requires the brokerage to return the excess funds, the brokerage shall do so within fourty-five (45) days of receipt of the Authority notification.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3220 Brokerage Reimbursements to Subcontractors

(1) Brokerages shall reimburse their non-emergent medical transportation (NEMT) subcontractors for the most cost-effective route from point of origin to point of destination that most benefits the client’s condition.

(2) Brokerages shall establish a base rate with its subcontractors. “Base rate” for all modes of transportation except ground and air ambulance means the rate the brokerage and its subcontractors agree on for each mode of transportation.

(3) If a subcontractor uses an ambulance as a stretcher car or van, the brokerage shall reimburse the subcontractor using the base rate for stretcher cars or vans.

(4) As an exception section (3) of this rule, brokerages shall pay ambulance subcontractors at the ambulance rate instead of the stretcher car or van rate when the transport exceeds two hours, necessitating a health care professional to care for the client during the ride.

(5) Brokerages shall not reimburse their subcontractors for waiting for clients to get to the vehicle or for assisting clients to get in or out of a vehicle.

(6) Brokerages may reimburse their subcontractors for waiting time:

(a) In special situations, such as when the subcontractor must wait for a client who is using the subcontractor’s gurney and cannot transfer to a gurney at a medical facility; or

(b) Because of a medical issue during the ride, such as:

(A) The client is nauseous or is vomiting after dialysis or chemotherapy; or

(B) The client needs to stop to get prescription medication or medical supplies related to the medical service.

(7) Brokerages shall reimburse their subcontractors at the base rate for ambulatory vehicles if the subcontractor provides a ride to an ambulatory client in a non-ambulatory vehicle.

(8) Brokerages may authorize a subcontractor to transport a non-ambulatory client in an ambulatory vehicle if the vehicle can accommodate and transport the client and if allowed by local ordinance. The brokerage shall reimburse its subcontractor at the non-ambulatory vehicle rate.

(9) The wheelchair base rate applies to the transport of a client with a reclining wheelchair; wheelchairs do not qualify as stretchers or gurneys.

(10) The following applies to reimbursement for deceased clients:

(a) If a client dies before the subcontractor arrives at the scene, the brokerage shall not reimburse its subcontractors; or

(b) If a client dies after the transport begins but before reaching the destination, the brokerage’s payment is limited to the base rate for the mode of transportation and mileage. For ambulance transports, the payment also would include costs for an extra attendant, if applicable.

(11) Brokerages may authorize shared-ride transports of two or more clients at the same time when the shared-ride transports are allowable under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(12) Brokerages shall reimburse subcontractors:

(a) At the full base rate for the first client and one-half the base rate for each additional client when all of these clients need the same mode of transportation, such as by wheelchair van; or

(b) At the full base rate for the client with the need for the highest mode of transportation and one-half the base rate of the appropriate mode of transportation for each additional client. This applies when the additional client needs a less costly mode of transportation than the first client. For example, the first client needs an ambulance, but the additional client needs a less costly wheelchair van.

(13) When transporting two or more clients at the same time, brokerages shall pay subcontractors only from the first pickup point to the final destination under the following circumstances:

(a) The clients have a single pick up point but different destinations;

(b) The clients have different pick up points but a single destination; or

(14) Brokerages shall reimburse subcontractors only for actual miles traveled, regardless of the number of clients transported.

(15) A brokerage shall not reimburse a subcontractor if:

(a) A county or city ordinance prohibits any charging for services identified in the medical transportation services administrative rules; or

(b) The subcontractor does not charge the public for such services.

(16) In accordance with costs and expenses reporting described in OAR 410-136-3200 a brokerage may require the subcontractor to provide documents and records to support the costs and expense that the brokerage must report to OHA.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 29-2014, f. & cert. ef. 5-20-14
DMAP 69-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3240 Client Reimbursed Mileage, Meals and Lodging

(1) The brokerage must prior authorize a client’s mileage, meals, and lodging to an Oregon Health Plan (OHP) or RHAF covered medical service in order for the client to qualify for reimbursement. If the brokerage prior authorized the travel costs, a client may request reimbursement up to 45 days after the travel.

(2) The client must return any documentation the brokerage requires before receiving reimbursement. Documentation required shall include a receipt for lodging.

(3) A client must be reimbursed within fourteen (14) days of the brokerage after verification of the client’s attendance at the appointment for the reimbursement request received.

(a) A brokerage may hold reimbursements under the amount of $10 until the client’s reimbursement reaches $10; or

(b) A brokerage must issue the client a notice within fourteen (14) days if the client reimbursement is denied for any reason. If the client reimbursement request is incomplete the brokerage shall take an additional fourteen (14) days to assist the client in completing the submission;

(4) Brokerages shall reimburse clients for meals when a client, with or without an attendant, travels a minimum of four (4) hours round-trip out of their local area. The travel, however, must span the following meal times:

(a) For a breakfast allowance, the travel must begin before 6 a.m.;

(b) For a lunch allowance, the travel must span the entire period from 11:30 a.m. through 1:30 p.m.; and

(5) Brokerages shall reimburse for meals at the Authority’s allowable rate.

(6) Brokerages shall not reimburse clients for meals that a hospital or other medical facility provides.

(7) Brokerages shall reimburse clients for lodging when:

(a) A client would otherwise be required to begin travel before 5 a.m. in order to reach a scheduled appointment;

(b) Travel from a scheduled appointment would end after 9 p.m.; or

(8) Brokerages shall reimburse for lodging at the Authority’s allowable rate or the actual cost of the lodging, whichever is less.

(9) Brokerages shall reimburse for meals or lodging for only one attendant, which may be a parent, to accompany the client if medically necessary but only if:

(a) The client is a minor child and unable to travel without an attendant;

(b) The client's attending physician provides a signed statement indicating the reason an attendant must travel with the client;

(d) The client is or may be unable to return home without assistance after the treatment or service.

(10) The brokerage shall not reimburse for the attendant's time or services.

(11) If a client’s health care provider admits the client for inpatient care, an attendant is no longer medically necessary because the facility provides all necessary services for the client. Therefore, the attendant is no longer eligible for lodging and travel expenses. The brokerage shall reimburse for meals and lodging for the attendant’s transportation home. However, the brokerage may pay for the attendant’s meals and lodging if it is more cost effective for the attendant to remain near the client to accompany the client on the return trip as allowed by section (12) of this rule.

(12) Upon the client’s release from inpatient care, if the attendant is medically necessary based on one of the conditions or circumstances listed in section (9) of this rule, the brokerage shall reimburse for the attendant to return to the inpatient facility to accompany the client on the return trip. This only applies if the brokerage prior authorizes the attendant’s travel.

(13) Brokerages shall not reimburse for mileage, meals, and lodging for an attendant visiting an inpatient client unless the physician provides a signed statement of the medical need. This exclusion includes, but is not limited to, parents of minors, breastfeeding mothers, and spouses.

(14) The state shall recover overpayments made to a client. Overpayments occur when the brokerage paid the client:

(a) For mileage, meals, and lodging, and another resource also paid:

(A) The client or;

(B) The ride, meal, or lodging provider directly;

(b) Directly to travel to medical appointments, and the client did not use the money for that purpose, did not attend the appointment, or shared the ride with another client whom the brokerage also directly paid;

(c) For common carrier or public transportation tickets or passes, and the client sold or otherwise transferred the tickets or passes to another person.

(15) If a person or entity other than the client or the minor client’s parent or legal guardian provides the ride, the brokerage may reimburse the person or entity that provided the ride. However, the client or the minor client’s parent or legal guardian must approve in writing of the reimbursement.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 29-2014, f. & cert. ef. 5-20-14
DMAP 69-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3260 Modifications Based on Client Circumstances

(1) A client may request modification of non-emergent medical transportation (NEMT) services when the NEMT driver:

(a) Threatens to harm the client or others in the vehicle;

(b) Drives or engages in other behavior that places the client or others in the vehicle at risk of harm;

(d) Presents a perceived or direct threat to the client or others in the vehicle.

(2) A brokerage may modify NEMT services when the client:

(a) Is threatening harm to the driver or others in the vehicle;

(b) Presents a direct threat to the driver or others in the vehicle;

(d) Engages in behaviors or circumstances that place the driver or others in the vehicle at risk of harm;

(e) Frequently does not show up for scheduled rides;

(f) Frequently cancels the ride on the day of the scheduled ride time;

(g) Engages in behaviors that cause local medical providers or facilities to refuse to provide further services without modifying NEMT services; or

(h) Has special needs that require special accommodations.

(2) For the purposes of this rule, “direct threat” means a significant risk to the health or safety of others and which:

(a) Cannot be eliminated or reduced to an acceptable level through the provision of auxiliary aids and services or through reasonably modifying policies, practices, or processes; and

(b) Is identified through an individual assessment that relies on current medical evidence or the best available objective evidence which shows:

(A) The nature, duration, and severity of the risk;

(B) The probability that a potential injury shall actually occur; and

(3) Reasonable modifications include, but are not limited to requiring the client to:

(a) Use a specific transportation subcontractor;

(b) Travel with an attendant;

(d) Drive themselves or locate someone to drive them and receive mileage reimbursement; or

(e) Confirm the ride with the brokerage on the day of or the day before the scheduled ride.

(4) Before requiring any modifications, the brokerage shall talk with the client about the reason for imposing a modification, explore modifications that are appropriate to the needs of the client and that address the health and safety concerns of the brokerages. The brokerage or client may include the client’s worker, or CCO in the discussion. The client may include other individuals in the discussion.

(5) Responses to requests for modification or auxiliary aids based on disability or other protected class status under state or federal rule or law must comply with the Americans with Disabilities Act and all other applicable state and federal laws and rules.

(6) Brokerages may not modify NEMT services under this rule unless the modification is permitted under this rule or required in order to accommodate a disability requiring modification or auxiliary aid.

(7) Brokerages may not make a reasonable modification based on the criteria in section (1)(a)-(g) in this rule that results in a denial of NEMT services to a client and must make all reasonable efforts to offer an appropriate alternative to meet the client’s needs under the circumstances.

(8) Brokerages shall draft policies and procedures that ensure the safety of all passengers in NEMT vehicles which shall include, without limitation, policies and procedures that comply with this rule and in accordance with OAR 410-136-3020 (13)(e). Brokerages shall include passenger safety policy and procedures in a OHP Open Card Member Handbook or in a stand-alone document, and ensure the information is available on the Brokerages’ website for passengers. Brokerages shall also provide passenger safety policy and procedures information to their NEMT subcontractors and require the NEMT subcontractors to follow the policies and procedures.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 11-2014, f. & cert. ef. 3-11-14
DMAP 58-2013(Temp), f. & cert. ef. 10-30-13 thru 4-28-14
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3280 Client Rights and Confidentiality

(1) Brokerages shall treat all information gathered on the client as privileged and confidential communications. The brokerage shall apply confidentiality policies to all requests for information from outside sources. Nothing prohibits the disclosure of information in summaries, statistical reports or other forms as long as the document does not identify particular individuals and cannot lead to the identification of individuals. Brokerages and any subcontractors may share information as necessary to serve the client effectively. The brokerage shall not divulge the information without the written consent of the client, the responsible parent of a minor child or the client’s legal guardian. The use or disclosure of information is limited to persons directly administrating NEMT services.

(2) Brokerages and their subcontractors shall comply with OAR 943-014-0300 through 943-014-0320 pertaining to access control if the Authority grants them access to any secure computer system or information asset.

(3) Brokerages and their subcontractors shall comply with the Authority’s non-discrimination and modification rules found at OAR 943-005-0000 to 943-005-0070.

(4) The brokerage shall not deny or allow subcontractors to deny any client NEMT services based on race, color, sex, gender, gender identity, gender presentation, sexual orientation, religion, national origin, creed, marital status, age, health status or the presence of any sensory, mental, intellectual, developmental, IQ score, or physical disability.

(5) Brokerages must treat clients and require subcontractors and all drivers to treat clients in accordance with OAR 410-120-1855, Client Rights and Responsibilities, including but not limited to:

(a) To ensure clients and their representatives have communications and materials explained in their preferred spoken or sign language;

(b) To ensure clients receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency.

(6) The brokerages shall have educational materials available for clients on its NEMT services. The Oregon Health Authority (Authority) must first approve the materials and document the approval in writing. Subcontractors shall use Authority approved NEMT education materials.

(7) As required by 42 CFR 431, a brokerage shall follow OAR 410-120-1855 through 410-120-1865 pertaining to contested case hearings when it denies a ride, with the following exceptions:

(a) The brokerage must immediately provide a secondary review by another employee when the initial screener denies a ride; and

(b) The brokerage must mail a notice of action to a client denied a ride within 72 hours of denying a ride explaining why the client's ride has been denied and hearing rights to appeal the denial.

(8) The brokerages shall reinstate a denied service consistent with 42 CFR 431.231 in the following circumstances:

(a) if action is taken without the advance notice required;

(b) if a beneficiary requests a hearing within ten (10) days after the date of action, or if determined action had resulted from other than the application of Federal or State law or policy; or

(9) Brokerages must have and maintain documentation pertaining to all authorization and denial of services. Upon the Authority’s request, brokerages shall provide documentation pertaining to discovery for any investigation, or for contested case hearings pursuant to OAR 410-120-1360.

(10) Brokerages shall provide documentation pertaining to discovery for or investigation of contested case hearings when the client, the responsible parent of a minor child or the client’s legal guardian requests the documentation. The brokerage shall provide the documentation to the client’s legal representative upon written consent from the client, the responsible parent of a minor child or the client’s legal guardian.

(11) Brokerages shall have and maintain policies and procedures which shall include, without limitation, policies and procedures that comply with this rule. Brokerages shall provide client rights and responsibilities policy and procedures information from this rule to its NEMT subcontractors and require the NEMT subcontractors to implement and follow such policies and procedures. Brokerages shall include client rights and responsibilities policy and procedures in their member handbooks and posted on their websites. Brokerages must monitor subcontractors’ compliance with client rights and responsibilities policies and procedures of this rule.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3300 Reports and Documentation

(1) Brokerages shall maintain documentation of rides denied and rides provided to clients. This documentation shall include, but is not limited, to:

(a) The name of the client and the person requesting the ride on behalf of the client, if applicable;

(b) The client's Oregon Health Plan (OHP) or RHAF medical care identification number;

(d) The mode of transport authorized for the client and a justification for authorizing a mode of transport that is not reasonably understandable;

(e) The location for picking-up the client and the destination;

(f) The medical reason for the appointment;

(g) The availability of other transportation resources and the justification for authorizing a ride when the client has other resources;

(h) The subcontractor assigned to give the ride and the date and time the brokerage notified the subcontractor of the assignment;

(i) The name of the employee who approved a ride and the name of the driver for the ride, as applicable; and

(j) In the case of a denial of a ride:

(A) The name of the employee who denied a ride;

(B) The name of the employee who performed the secondary review before denying the ride;

(D) The date on the notice of action the brokerage mailed to the client;

(E) Documentation on the brokerage’s review, resolution, or disposition of the matter, if applicable, including the reason for the decision and the date of the resolution or disposition; and

(F) Notations of oral and written communications with the client and documentation of the outcome of any appeal of a denied service.

(2) The brokerage shall retain the documentation on denials of rides for three calendar years, even if the brokerage is no longer a Medicaid enrolled provider before the end of the three years. The Authority may request this information at any time during the three year retention period.

(3) The brokerage shall maintain service and billing files organized by subcontractor that justify the number of transports and with cross references to actual rides and specific clients. The record keeping system developed and maintained by brokerages and their subcontractors shall include sufficient detail and clarity to permit internal and external review to validate claim submissions and to assure NEMT services are provided consistent with the documented needs of the client. Brokerages information for actual rides shall include the date, mode of transport, the driver’s first and last name.

(4) The brokerages shall report monthly on estimated revenue and expenses that affect the balance of the working capital reserve amount. The report must contain the following costs as they pertain to providing NEMT services:

(a) Sub-totals of administrative expenses, including:

(A) Salaries and wages of the brokerage’s employees;

(B) Payroll related expenses for the brokerage’s employees;

(D) Computer hardware and software purchased, leased or licensed;

(E) Office supplies such as stamps, paper or printing;

(F) Non-computer related equipment purchased, leased or licensed;

(G) Telephone;

(H) Administrative support and other indirect charges;

(I) Education and training;

(J) Building expenses such as leases, rents, security, janitorial services and repairs that retain the property’s operating condition but do not add to the permanent value of the property;

(K) Subcontractor identification and drug testing, such as fingerprinting and drug analysis;

(L) Legal expense not related to the Authority, such as attorney fees; fines or penalties;

(M) Indirect expenses, such as accounting, human resources, risk management or insurance;

(N) Sub-contracts for operations or temporary employees;

(O) Required driver training, if applicable;

(P) The client satisfaction survey, if applicable;

(Q) Software maintenance, if applicable; and

(R) Details of other administrative expenses not specified above.

(b) The number and costs of the following:

(A) Stretcher car rides;

(B) Wheelchair rides;

(D) Secured transports;

(E) Bus tickets;

(F) Bus passes;

(G) NEMT ambulance transports;

(H) Reimbursements to clients; and

(I) Commercial transports.

(d) Information on the brokerage’s working capital reserve, including:

(A) The Authority-calculated working capital reserve;

(B) The estimated working capital reserve as of the beginning of the fiscal year;

(D) The difference between above sub-sections (B) and (C) of this rule.

(5) The financial reports must show the number of rides that volunteer drivers provide.

(6) Brokerages must submit the financial report required in Section (4) of this rule within 45 days of the end of the reporting month.

(7) Brokerages shall submit a cost allocation plan that includes anticipated expenses, certified by the brokerage’s Chief Financial Officer, to the Authority no later than April 1 of each year for the upcoming fiscal year.

(8) Brokerages must report monthly on data that meets the delivery and content specifications as defined by the Authority.

(a) monthly data for quality assurance must include at minimum the following:

(A) Driver Cancellations reported as a numeric value of the total number of times within the reporting period that a driver cancels a ride less than 24 hours in advance, resulting in client not receiving scheduled ride;

(B) Driver No-Shows reported as a numeric value of the total number of times within the reporting period that a driver was not at pick up location as pre-arranged resulting in client not receiving scheduled ride;

(C) Client Cancellations reported as a numeric value of total number of times within the reporting period that a clients cancel a ride less than 24 hours in advance;

(D) Client No-Shows reported as a numeric value of the total number of times within the reporting period that a client was not at pick up location as pre-arranged, after the allowed 15-minute window of time, resulting in a ride cancellation;

(E) Late Rides reported as a numeric value of the total number of rides within the reporting period where driver arrived 15 minutes or more past scheduled pick-up time.

(F) Rides scheduled reported as a numeric value of the total number of rides scheduled in the reporting period regardless of whether driver/member no-show or cancelled.

(G) Rides denied reported as a numeric value of the total number of rides denied by brokerage during the reporting period.

(b) Brokerages must submit monthly data quality assurance report to the Authority no later than 45 days after the end of each month within each calendar year.

(9) Brokerages must maintain written policies and procedures outlining the activities of NEMT services for ongoing monitoring, evaluation, and improvement of the quality and appropriateness of NEMT services, and with procedures for processes.

(10) Brokerages must submit written policies and procedures to the Authority no later than December 1 of each year for the upcoming calendar year.

(11) Brokerages must develop and conduct a client satisfaction survey, including at minimum the following:

(a) Processes for conducting client satisfaction surveys at least annually;

(b) Satisfaction surveys must be sent to a minimum of five percent of all clients who scheduled NEMT rides;

(c) Submit completed client satisfaction survey results to the Authority, at least annually, for review of results to identify potential areas of enhancement or improvement within the program.

(12) Brokerages must maintain a log of all OHA Client grievances, complaints that are referred by brokerage to the Authority, and of which brokerage receives notice from subcontractors or the Authority. The log shall identify at minimum:

(a) Client name;

(b) Date of the grievance;

(d) Resolution; and

(e) Date of resolution.

(13) The Authority may request, and the brokerage shall provide, other reports or information not specified in sections 1 through 11 of this rule. OHA has the right to request all NEMT documentation, information, reports, phone call recordings, grievances or other complaints submitted, policies and procedures, systems, facilities that provide or otherwise relate to NEMT services for purposes of determining compliance.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3320 Audits

(1) The Oregon Health Authority (Authority), the Oregon Secretary of State Audits Division, the Oregon Department of Justice, Medicaid Fraud Control Unit (MFCU) and the federal government may audit the brokerage’s and its subcontractor’s records at least annually. When the Authority determines that an overpayment has been made to a brokerage, the amount of overpayment is subject to recovery. The audit shall include, but is not limited to, the following areas:

(a) Financial status;

(b) Performance and quality of the service;

(d) The relationship between the funds provided by the Authority and the amounts expended by brokerages or billed by subcontractors and that the use of funds is reasonable and necessary to provide quality service.

(2) The Authority or its designee, the Oregon Secretary of State Audits Division, the MFCU, and the federal government may review the brokerage’s, subcontractor’s or provider’s or driver’s records whenever necessary to verify delivery of service, financial and operational status, and compliance with OARs or to investigate unresolved questions of fact or suspected overpayment. Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the NEMT service was not provided in accordance with applicable Chapter 410 division 120 and division 136 rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment.

(3) As specified by 42 CFR 455.17, brokerages, subcontractors, providers and drivers shall promptly report to the Authority any suspected fraud, abuse, or waste of NEMT services. The Brokerage shall cooperate and require all subcontractors to cooperate in good faith and allow access to all records and its subcontractors and provider’s records to allow federal and state agencies to perform investigations and audits of suspected fraud, abuse, or waste. The brokerages and any subcontractor shall immediately allow access to inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted.

(4) If the Authority determines there exists a credible allegation of fraud or abuse the Authority may take the actions necessary including but not limited to suspending or terminating a brokerage, subcontractor, provider, or driver from participation in the medical assistance programs, suspending payments or seeking recovery of payments made, or imposing other sanctions provided under state law or regulations. When directed by the Authority, the brokerages shall immediately suspend payments to a subcontractor, provider, or driver that the State determines there is a credible allegation of fraud in accordance with 42 CFR § 455.23.

(5) Brokerages shall not execute contracts with or pay for NEMT services provided by subcontractors, providers or drivers who are currently suspended, debarred, or otherwise excluded from participating in Medicaid, Medicare, CHIP, or who have been convicted of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, XXI, or XX of the Social Security Act or related laws. The brokerage shall immediately notify the Authority when it identifies an excluded provider (individuals or entities).

(6) Brokerages are prohibited from notifying or otherwise discussing any Authority or federal agencies investigation with any person(s) who are the subject of the investigation or taking any action against the person(s) or entity, such as termination of employment or contract, without the written permission of the Authority or MFCU while the investigation is ongoing.

(7) Brokerages or subcontractors that are currently subject to sanction by the Authority or the brokerage or subcontractor, a person with ownership or control of the brokerage or subcontractor, or a brokerage’s or subcontractor’s managing employee is excluded, sanctioned or suspended by the federal government or another state from Medicare or Medicaid participation the brokerage or subcontractor is not eligible for enrollment, consistent with OAR 410-120-1400, except when the Agency determines good cause exists, in accordance with 42 CFR 455.23.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3340 Brokerage Service Areas

(1) Brokerages enrolled with the Oregon Health Authority (Authority) shall arrange and pay for NEMT services to all eligible clients in the counties shown in Table 136-3340.

(2) Oregon Health Plan (OHP) clients and RHAF clients residing in Oregon shall use only the brokerages available in their county of residence unless they have permission from their local brokerage to use another brokerage.

(3) Nothing in this rule precludes brokerages from coordinating to provide rides to clients in another brokerage if it would be more cost effective or provide better service for the client.

[ED. NOTE: Table referenced is available from the Oregon Health Authority (OHA) and on the Authority’s website.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3360 Discontinuation of Brokerage as Enrolled Provider

(1) A brokerage may discontinue being an enrolled provider for NEMT services only with notice to the Oregon Health Authority (Authority). The following establishes the requirements for notice:

(a) If the reason is for the brokerage’s convenience:

(A) The effective date must be at least 90 days after the brokerage sends written notice; and

(B) the effective date must be on the first calendar date of the month.

(b) The brokerage must provide 45 days advance written notice if the brokerage does not obtain funding, appropriations and other expenditure authorizations from its governing body, federal, state or other sources sufficient to permit the brokerage to satisfy its requirements pursuant to these rules (OAR 410-136-3000 through 410-136-3360);

(c) Immediately upon written notice if the Oregon Legislative Assembly, the federal government or a court interprets, modifies or changes Oregon statutes or federal laws, regulations or guidelines in such a way that the brokerage immediately has no authority to satisfy the requirements of these rules.

(2) The Authority may discontinue allowing a brokerage to provide NEMT services as an enrolled provider only with notice to the brokerage. The following establishes the requirements for notice:

(a) If the reason is for the Authority’s convenience:

(A) The effective date must be at least 90 days after the Authority sends written notice; and

(B) the effective date must be on the first calendar date of a month.

(b) The Authority must provide 45 days advance written notice if the Authority does not obtain funding, appropriations and other expenditure authorizations from its governing body, federal, state or other sources sufficient to meet its payment obligations pursuant to OAR 410-136-3200, Reimbursement and Accounting for all Modes of Transportation;

(c) Immediately upon written notice if the Oregon Legislative Assembly, the federal government or a court interprets, modifies or changes Oregon statutes or federal laws, regulations or guidelines in such a way that the Authority immediately has no authority to provide NEMT services pursuant to these rules;

(d) Immediately upon written notice to the brokerage if the Oregon Legislative Assembly or Emergency Board reduces the Authority’s expenditure authorization, resulting in the following:

(A) The Authority cannot meet its payment obligations pursuant to OAR 410-136-3200, Reimbursement and Accounting for all Modes of Transportation; and

(B) The effective date for the reduction in expenditure authorization is less than 45 days from the date the Legislative Assembly or Emergency Board takes the action.

(e) Immediately upon written notice to the brokerage if a law or regulation requires a brokerage to have any license or certificate, and the license or certificate is denied, revoked, suspended, not renewed or changed in such a way that brokerage no longer meets requirements to deliver NEMT services. The Authority may only exercise this right with respect to the particular service impacted by the loss of the licensure or certification;

(f) Immediately upon written notice to the brokerage, if the Authority determines the brokerage or any of its subcontractors, have endangered or are endangering the health or safety of a client or others.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13

Or. Admin. R. 410-136-3370 General Requirements for GEMT

(1) The Ground Emergency Medical Transportation (GEMT) program is a voluntary program that makes supplemental payments to eligible GEMT providers who furnish qualifying emergency ambulance services to Oregon Health Authority (Authority) Medicaid recipients:

(a) The supplemental payment covers the gap between the eligible GEMT provider’s total allowable costs for providing GEMT services as reported on the Centers for Medicare and Medicaid Services (CMS) approved cost report and the amount of the base payment, mileage, and all other sources of reimbursement;

(b) The Authority makes supplemental payments only up to the amount uncompensated by all other sources of reimbursement. Total reimbursements from Medicaid including the supplemental payment may not exceed one hundred percent of actual costs;

(c) The supplemental payments shall be made at least annually on a lump-sum basis after the conclusion of each state fiscal year. These payments are not an increase to current fee-for-service (FFS) reimbursement rates;

(d) This supplemental payment applies only to GEMT services rendered to Oregon FFS Medicaid recipients by eligible GEMT providers on or after July 1, 2017.

(2) Definitions:

(a) “Agency” means the Oregon Health Authority (Authority);

(b) Advanced Life Support” means special services designed to provide definitive prehospital emergency medical care, including but not limited to cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation, advanced airway management, intravenous therapy, administration of drugs and other medicinal preparations, and other specified techniques and procedures;

(c) “Allowable Costs” means an expenditure that complies with the regulatory principles as listed in chapter 2 of the Code of Federal Regulations (CFR) Section 200;

(d) “Basic Life Support” means emergency first aid and cardiopulmonary resuscitation procedures to maintain life without invasive techniques;

(e) “Contracts with a Local Government” means contracts pursuant to a county plan for ambulance and emergency medical services that is approved by the Oregon Health Authority with a;

(A) City, county, an Indian tribe as defined in Section 4 of the Indian Self-Determination and Education Assistance Act; or

(B) Local service district, including but not limited to;

(i) A rural fire protection district; or

(ii) All administrative subdivisions of such city, county, or local service district.

(f) “Direct Costs” means all costs that can be identified specifically with a particular final cost objective in order to meet emergency medical transportation requirements. This includes unallocated payroll costs for the shifts of personnel, medical equipment and supplies, professional and contracted services, travel, training, and other costs directly related to the delivery of covered medical transport services;

(g) “Eligible GEMT Provider” means a GEMT provider that meets all the eligibility requirements described in OAR 410-136-3370(3);

(h) “Federal Financial Participation (FFP)” means the portion of medical assistance expenditures for emergency medical services that are paid or reimbursed by the Centers for Medicare and Medicaid Services in accordance with the State Plan for medical assistance. Clients under Title XIX are eligible for FFP;

(i) “GEMT Services” means the act of transporting an individual by ground from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the patient, as well as the advanced, limited-advanced, and basic life support services provided to an individual by eligible GEMT providers before or during the act of transportation;

(j) “Governmental Unit” means the entire state, local, or federally-recognized Indian tribal government, including any component thereof;

(k) “Indirect Costs” means the costs for a common or joint purpose benefitting more than one cost objective that is allocated to each objective using an agency-approved indirect rate or an allocation methodology;

(l) “Limited Advanced Life Support” means special services to provide prehospital emergency medical care limited to techniques and procedures that exceed basic life support but are less than advanced life support services;

(m) “Publicly Owned or Operated” means a unit of government that is a state, a city, a county, a special purpose district, or other governmental unit in the state that has taxing authority, has direct access to tax revenues, or is an Indian tribe as defined in Section 4 of the Indian Self-Determination and Education Assistance Act;

(n) “Service Period” means July 1 through June 30 of each Oregon State Fiscal Year (SFY);

(o) “Shift” means a standard period of time assigned for a complete cycle of work, as set by each eligible GEMT provider. The number of hours in a shift may vary by GEMT provider but shall be consistent to each GEMT provider.

(p) “Treatment in place” means EMT services (basic, limited-advanced, and advanced life support services) provided by a Medicaid-enrolled EMS professional to an individual who is released on the scene without transportation by ambulance to a medical facility.

(3) GEMT Provider Eligibility Requirements:

(a) To be eligible for supplemental payments, GEMT providers shall meet the following requirements:

(A) Be enrolled as an Oregon Health Plan Medicaid provider for the period being claimed on their annual cost report; and

(B) Provide ground emergency medical transport services to Medicaid recipients.

(b) GEMT providers must classify as a Governmental Unit provider in accordance with 2 CFR 200.

(4) Supplemental Reimbursement Methodology General Provisions:

(a) Computation of allowable costs and their allocation methodology shall be determined in accordance with the CMS Provider Reimbursement Manual (CMS Pub. 15-1), CMS non-institutional reimbursement policies, and 2 C.F.R. Part 200, which establish principles and standards for determining allowable costs and the methodology for allocating and apportioning those expenses to the Medicaid program, except as expressly modified below;

(b) Medicaid base payments to the eligible GEMT providers for providing GEMT services are derived from the ambulance FFS fee schedule established for reimbursements payable by the Medicaid program by procedure code. The primary source of paid claims data, managed care encounter data, and other Medicaid reimbursements is the Oregon Medicaid Management Information System (MMIS). The number of paid Medicaid FFS GEMT transports is derived from and supported by the MMIS reports for services during the applicable service period;

(c) The total uncompensated care costs of each eligible GEMT provider available to be reimbursed under this supplemental reimbursement program shall equal the shortfall resulting from the allowable costs determined using the Cost Determination Protocols for each eligible GEMT provider providing GEMT services to Oregon Medicaid beneficiaries, net of the amounts received and payable from the Oregon Medicaid program and all other sources of reimbursement for such services provided to Oregon Medicaid beneficiaries. If the eligible GEMT providers do not have any uncompensated care costs, then the provider may not receive a supplemental payment under this supplemental reimbursement program. Total reimbursement from Medicaid may not exceed one hundred percent of actual cost of providing services to Oregon Medicaid beneficiaries.

(5) Cost Determination Protocols:

(a) An eligible GEMT provider’s specific allowable cost per-medical transport rate shall be calculated based on the provider’s audited financial data reported on the CMS-approved cost report. The per-medical transport cost rate shall be the sum of actual allowable direct and indirect costs of providing medical transport services divided by the actual number of medical transports provided for the applicable service period;

(b) Direct costs for providing medical transport services include only the unallocated payroll costs for the shifts when personnel dedicate 100 percent of their time to providing medical transport services, medical equipment and supplies, and other costs directly related to the delivery of covered services, such as first-line supervision, materials and supplies, professional and contracted services, capital outlay, travel, and training. These costs shall be in compliance with Medicaid non-institutional reimbursement policy and are directly attributable to the provision of the medical transport services;

(A) Eligible GEMT providers that receive more than $35 million in direct federal awards shall either have a Cost Allocation Plan (CAP) or a cognizant agency-approved indirect rate agreement in place with its federal cognizant agency to identify indirect cost. If the eligible GEMT provider does not have a CAP or an indirect rate agreement in place with its federal cognizant agency and it would like to claim indirect cost in association with a non-institutional service, it shall obtain one or the other before it can claim any indirect cost; or

(B) Eligible GEMT providers that receive less than $35 million of direct federal awards are required to develop and maintain an indirect rate proposal for purposes of audit. In the absence of an indirect rate proposal, eligible GEMT providers may use methods originating from a CAP to identify its indirect cost. If the eligible GEMT provider does not have an indirect rate proposal on file or a CAP in place and it would like to claim indirect cost in association with a non-institutional service, it shall secure one or the other before it can claim any indirect cost; or

(C) Eligible GEMT providers that receive no direct federal funding can use any of the following previously established methodologies to identify indirect cost:

(i) A CAP with its local government; or

(ii) An indirect rate negotiated with its local government; or

(iii) Direct identification through use of a cost report.

(D) If the eligible GEMT provider never established any of the above methodologies, it may do so, or it may elect to use the 10 percent de minimis rate to identify its indirect cost.

(d) The GEMT provider-specific, per-medical transport cost rate is calculated by dividing the total net medical transport allowable costs of the specific provider by the total number of medical transports provided by the provider for the applicable service period;

(e) The costs associated with Treatment in place shall not be included in the total allowable costs and must not be counted as an allowable medical transport.

(6) Interim Supplemental Payment:

(a) Each eligible GEMT provider shall compute the annual cost in accordance with OAR 410-136-3370(5) and shall submit the completed annual as-filed cost report to the Authority within five months after the close of the state’s fiscal year;

(b) The Authority shall make annual interim supplemental payments to eligible GEMT providers. The interim supplemental payment for each eligible GEMT provider is based on the provider’s completed annual cost report in the format prescribed by the Authority and approved by CMS for the applicable cost reporting year;

(c) To determine the interim supplemental GEMT payment rate, the Authority shall use the most recently filed cost reports of all eligible GEMT providers to determine the average cost per transport, which varies between the providers.

(7) Cost Settlement Process:

(a) The payments and the number of transport data reported in the as-filed cost report shall be reconciled to the Authority’s MMIS reports generated for the cost reporting period within one year of receipt of the as-filed cost report. The Authority shall make adjustments to the as-filed cost report based on the reconciliation results of the most recently retrieved MMIS report;

(b) Each eligible GEMT provider shall receive payments in an amount equal to the greater of the interim payment or the total CMS approved Medicaid-allowable costs for GEMT services;

(c) The Authority shall perform a final reconciliation where it will settle the provider’s annual cost report as audited within the following calendar quarter. The Authority shall compute the net GEMT allowable costs using audited per-medical transport cost and the number of fee-for-service GEMT transports data from the updated MMIS reports. Actual net allowable costs shall be compared to the total base and interim supplemental payment and settlement payments made and any other source of reimbursement received by the provider for the period;

(d) If, at the end of the final reconciliation, it is determined that the eligible GEMT provider is overpaid, the provider shall return the overpayment to the Authority, and the Authority shall return the overpayment to the federal government pursuant to section 433.316 of Title 42 of the Code of Federal Regulations. If an underpayment is determined, then the eligible GEMT provider shall receive an interim supplemental payment in the amount of the underpayment. Overpayments and underpayments shall be processed in accordance with OAR 410-120-1397;

(e) The provider may appeal an Authority notice of overpayment in the manner provided in OAR 410-120-1560.

(8) Eligible GEMT Provider Reporting Requirements:

(a) Submit CMS approved cost reports to the Authority no later than five months after the close of the SFY, unless the eligible GEMT provider made a written request for an extension and such request is granted by the Authority;

(b) Provide any supporting documentation to serve as evidence supporting information on the cost report and the cost determination, if specifically requested by the Authority;

(c) Keep, maintain, and have readily retrievable such records to fully disclose reimbursement amounts that the eligible GEMT provider is entitled to and any other records required by CMS;

(d) Comply with the allowable cost requirements provided in Part 413 of Title 42 of the Code of Federal Regulations, 2 CFR Part 200, and Medicaid non-institutional reimbursement policy.

(9) Agency Responsibilities:

(a) The Authority shall, on an annual basis, submit any necessary materials to the federal government to provide assurances that claims shall include only those expenditures that are allowable under federal law;

(b) The Authority shall complete the audit and final reconciliation process of the interim supplemental payments for the service period within nine months of the postmark date of the cost report and conduct on-site audits as necessary.

History

Statutory/Other Authority: ORS 413.234
Statutes/Other Implemented: ORS 413.235
DMAP 76-2023, amend filed 09/19/2023, effective 09/19/2023
DMAP 23-2019, adopt filed 06/25/2019, effective 07/01/2019

Or. Admin. R. 410-136-3371 Provider Requirements and Payment Processing for the CCO GEMT Supplemental Payments

(1) Definitions:

(a) “Coordinated Care Organization” has the meaning defined in OAR 410-141-3500.

(b) "Ground Emergency Medical Transportation Provider" and "GEMT Provider" each means a GEMT provider that meets all the eligibility requirements as defined in the 42 CFR §438.6(c) Preprint.

(c) "Ground Emergency Medical Transportation Services" and "GEMT Services" each means the act of transporting an individual by ground from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the patient as described in the 42 CFR §438.6(c) Preprint.

(d) “Managed Care Entity” has the meaning defined in OAR 410-141-3500.

(e) "Participating Provider" has the meaning defined in OAR 410-141-3500.

(f) "Qualified Directed Payment" means a supplemental payment made by the Authority to CCOs for GEMT providers' qualifying services when rendered by provider classes as defined in 42 CFR §438.6(c) Preprint forms approved by Centers for Medicare and Medicaid Services (CMS).

(g) "Supplemental Payment" means a payment amount set by the Authority for each approved procedure code to supplement allowable costs for GEMT services.

(h) "§438.6(c) Preprint" means a 42 CFR §438.6(c) Preprint approved by U.S. Department of Health and Human Services CMS for Qualified Directed Payments to GEMT Providers for GEMT Services rendered during the applicable CCO contract rating period.

(2) GEMT Provider Eligibility Requirements:

(a) To be eligible for supplemental payments, GEMT providers shall meet the following requirements:

(A) Be licensed by the State of Oregon to provide emergency medical transportation services for the approved service period receiving supplemental payment;

(B) Be enrolled as an Oregon Health Plan (OHP) Medicaid provider for the approved service period receiving supplemental payment;

(b) Be a Governmental Unit provider in accordance with 2 CFR 200.

(A) Be a participating provider having a contractual agreement with a CCO on the date of GEMT services; and

(B) Have an agreement in place with the Oregon Health Authority (Authority) for the approved service period to allow for transfer of funds between participating GEMT provider and the Authority to supplement the allowable costs of providing qualifying emergency medical services to CCO members.

(3) Supplemental qualified directed payment process:

(a) A GEMT provider may participate in the GEMT supplemental payment program described in this rule if the GEMT provider is a participating provider in accordance with OAR 410-141-3500 on the date of service during the approved service period;

(b) The GEMT CCO Supplemental Payment Program is for supplemental payments made by the Authority to CCOs for GEMT providers' qualifying services when rendered by GEMT providers for the approved service period;

(c) In accordance with 42 CFR §438.6(c)(2)(i)(A), the supplemental payments are based on paid CCO member encounters in the Medicaid Management Information System (MMIS) for approved qualifying GEMT services’ procedure codes;

(d) The Authority shall pay any federal financial participation received from CMS, for qualifying GEMT services, to the CCO;

(e) The CCO shall increase, by the same amount, the amount of reimbursement paid to the appropriate GEMT provider;

(f) The non-federal share portion of the supplemental qualified directed payment is contributed by GEMT providers only;

(g) The GEMT provider shall agree to pay a fee to reimburse the Authority for the costs of administering the program. The fee may not exceed 20 percent of the supplemental payment provided;

(h) The Authority may adjust the amount of supplemental payments based on actual utilization and available GEMT funds for the period receiving supplemental payment. Qualified services rendered must be in accordance with OAR 410-120-1280 through 410-120-1340 for submission of claims and adhere to the record keeping and documentation requirements for services as described.

(4) Reporting and Billing Processes:

(a) The Authority shall combine the qualified encounters into a report to assist CCOs in distributing the program's supplemental funds to the appropriate GEMT provider in the manner agreed to by CCO and GEMT provider.

(A) In 2021 the report shall be distributed at least once to each CCO and each GEMT provider;

(B) In each subsequent program year that is approved by CMS, the report shall be distributed monthly to each CCO and each GEMT provider.

(b) After receipt of the report, CCOs shall submit a qualified directed payment for the amount indicated on the report to an account established by the appropriate GEMT provider;

(A) Adjustments shall be processed through the MMIS and included in the subsequent monthly report;

(B) If an error is identified in the monthly report, the CCO shall make the payment based on the original amount provided in the report. The Authority shall identify separately the correction in the following month's report and adjust the total payment amount to account for the error.

(c) Payment by the CCO as a MCE to participating providers for qualifying GEMT services shall be in accordance with OAR 410-141-3565 Managed Care Entity Billing;

(d) Consistent with OAR 410-141-3610, GEMT supplemental payments are considered premium equivalents and subject to the MCE assessment under OAR 410-141-3601.

(5) Quality Measurement:

(a) In accordance with 42 CFR §438.6(c)(2)(i)(C), this payment arrangement must advance at least one of the goals and objectives in Oregon's Medicaid quality strategy required per 42 CFR §438.340 and the Authority will review progress on the advancement of the state's goal(s) and objective(s) in the quality strategy identified in this section;

(b) GEMT providers shall submit the quality measurement data specified in the §438.6(c) Preprint.

(6) Authority Responsibilities:

(a) The Authority shall apply for program authorization through a §438.6(c) Preprint for each calendar year;

(b) The Authority shall make a supplemental payment only if the GEMT provider meets criteria established by the Authority for the GEMT CCO Supplemental payment program in accordance with applicable federal requirements approved by CMS for the applicable program year;

(c) The Authority shall make a supplemental payment consistent with §438.6(c) Preprint approved with CMS for qualified paid encounters as described in Section 3 of this rule, with an approved procedure code that meets criteria for payment established by the Authority, up to one encounter, per CCO member, per day;

(d) Upon receipt of an acceptable funds transfer from GEMT provider consistent with Section 3 of this rule, the Authority shall verify data received and draw the federal funds in an amount consistent with the applicable Oregon Federal Medical Assistance Percentage (FMAP).

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 413.234 & 413.235
DMAP 53-2022, adopt filed 06/01/2022, effective 06/02/2022
DMAP 48-2021, temporary adopt filed 12/08/2021, effective 12/10/2021 through 06/07/2022

Or. Admin. R. 410-136-3372 General Requirements for Ground Emergency Medical Transportation Emergency Medical Services Transport Private Provider Program

(1) The Ground Emergency Medical Transportation (GEMT) Emergency Medical Services Transport (EMST) private provider program makes supplemental payments to eligible GEMT EMST private providers who furnish qualifying emergency ambulance services to Oregon Health Authority (Authority) Medicaid recipients:

(a) The supplemental payment is for an add-on reimbursement fee to the base rates for eligible emergency medical transportation services. The supplemental payment is an add on to the base rates for eligible emergency medical transportation services, excludes Emergency Medical Services (EMS) air transports. The calculation is based on the gross receipts reported on the Centers for Medicare and Medicaid Services (CMS) approved data request template;

(b) The Authority makes supplemental payments only up to the amount calculated by the gross receipts. Total reimbursements from Medicaid including the supplemental payment may not exceed one hundred percent of actual costs;

(c) The supplemental payment shall cover GEMT EMST private providers and shall be applied in lump sum payment at least annually to eligible providers using the Healthcare Common Procedure Coding System (HCPCS) emergency transport codes.  OHA will apply the supplemental payment only to GEMT EMST private provider services rendered to FFS Medicaid members by eligible GEMT EMST Private Providers on or after April 1, 2023;

(d) The supplemental payments shall be made at least annually;

(e) The base rates for GEMT EMST private providers shall not change with this amendment to Oregon’s Medicaid’s State Plan that authorizes federal participation in this program.

(2) Definitions:

(a) “Authority” means the Oregon Health Authority;

(b) “Advanced Life Support” means special services designed to provide definitive prehospital emergency medical care, including but not limited to, cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation, advanced airway management, intravenous therapy, administration with drugs and other medicinal preparations, and other specified techniques and procedures;

(c) “Basic Life Support” means emergency first aid and cardiopulmonary resuscitation procedures to maintain life without invasive techniques;

(d) “Eligible Emergency Medical Services Transport Private Provider” means an EMS private provider that meets all the eligibility requirements described in (Section 2e) below. A nonfederal or nonpublic entity that:

(A) Employs individuals who are licensed by the Authority under ORS chapter 682 to provide emergency medical services; and

(B) Contracts with a local government pursuant to a plan described in ORS 682.062.

(e) “Emergency Medical Services” means the act of transporting an individual by ground from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the patient, as well as the advanced, limited-advanced, and basic life support services provided to an individual by Eligible Emergency Medical Services Provider before or during the act of transportation.

(A) This includes to assess, treat, and stabilize the individual’s medical condition; or

(B) Prepare and transport the individual to a medical facility.

(f) “Emergency Medical Services Transport” means an emergency medical services provider’s evaluation of an individual experiencing a medical emergency and the transportation of the individual to the nearest medical facility capable of meeting the needs of the individual. For the purposes of this state plan, EMS air transports are excluded;

(g) “Emergency Medical Services Fund” is a fund established in the state treasury, separate and distinct from the General Fund. The Emergency Medical Services Fund consist of moneys collected by the Authority as a quality assurance fee;

(h) “Federal Financial Participation (FFP)” means the portion of medical assistance expenditures for emergency medical services that are paid or reimbursed by the Centers for Medicare and Medicaid Services in accordance with the State Plan for medical assistance. Clients under Title XIX are eligible for FFP;

(i) “Gross Receipts” means gross payments received as patient care revenue for emergency medical services transports, determined on a cash basis of accounting. Gross receipts do not include Medicaid Supplemental Reimbursement pursuant to Attachment 4.19-B, pages 31-39 of Oregon’s Medicaid State Plan;

(j) “Local Government” means all cities, counties and local service districts located in this state, and all administrative subdivisions of those cities, counties and local service districts as defined in ORS 174.116;

(k) “Limited Advanced Life Support” means special services to provide prehospital emergency medical care limited to techniques and procedures that exceed basic life support but are less than advanced life support services;

(l) “Treatment in Place” means EMT services (basic, limited-advanced, and advanced life support services) provided by a Medicaid-enrolled EMS professional to an individual who is released on the scene without transportation by ambulance to a medical facility;

(m) “Usual Charge” means the lesser of the following unless prohibited by federal statute or regulation:

(A) The providers charge per unit of service for the majority of non-medical assistance users of the same service based on the preceding months charges;

(B) The providers lowest charge per unit of service on the same date that is advertised, quoted, or posted. The lesser of these applies regardless of the payment source or means of payment;

(C) Where the provider has established a written sliding fee scale based upon income for individuals and families with income equal to or less than 200 percent of the federal poverty level, the fees paid by these individuals and families are not considered in determining the usual charge. Any amounts charged to third party resources are to be considered.

(3) GEMT EMST Private Provider Eligibility Requirements. To be eligible for the supplemental payment, GEMT EMST private providers must meet all the following requirements:

(a) Be enrolled as an Oregon Health Plan Medicaid provider;

(b) Provide ground emergency medical transport services to Medicaid recipients;

(4) Enhanced Reimbursement Methodology:

(a) A uniform supplemental payment rate per emergency transport shall be determined at least annually and shall not exceed one hundred percent (100%) of the difference between Medicaid payments otherwise made to each GEMT EMST private provider for EMS services (base rates) and the usual charge for the service;

(b) Medicaid base rate to the GEMT EMST private providers for providing EMS services are derived from the ambulance FFS fee schedule established for reimbursements payable by the Medicaid program by procedure code:

(A) The primary source of paid claims data, managed care encounter data, and other Medicaid reimbursements is the Oregon Medicaid Management Information System (MMIS);

(B) The number of paid Medicaid EMS transports is derived from and supported by the MMIS reports and the data from the Data Request Report for services during the applicable twelve-month period.

(c) The ambulance add-on payments shall not exceed the funding collected by OHA as a quality assurance fee specified in OAR 410-136-3373 in the Emergency Medical Services Fund established in ORS 413.234.  Reimbursement may not exceed the costs for the emergency medical service transport, less the amount of reimbursement that the emergency medical services provider is eligible to receive from all public and private sources;

(d) Supplemental payments for each GEMT EMST private provider shall be calculated for each provider at least annually by multiplying the uniform add-on rate by the provider’s volume of Medicaid transports billed with Healthcare Common Procedure Coding System (HCPCS) codes A0429 BLS Emergency, A0427 ALS Emergency (Level 1). A0998 Ambulance Treatment in place will be paid at least annually as determined through the Medicaid Management Information System if federally approved for this program supplemental payments.

(e) GEMT EMST private providers not licensed within the State of Oregon shall not receive the enhanced supplemental payment.

(5) Eligible GEMT EMST Private Provider Reporting Requirements:

(a) Submit CMS approved data request template to the Authority;

(b) Provide any supporting documentation to serve as evidence supporting information on the data request template, if specifically requested by the Authority.  Any supporting documentation provided to the Authority is protected and not subjected to a public records release;

(c) Keep, maintain, and have readily retrievable such records to fully disclose reimbursements amounts that the eligible GEMT EMST private provider is entitled to, and any other records required by CMS for seven years.

(6) Agency Responsibilities:

(a) The Authority shall submit any necessary materials to the federal government to provide assurances that all gross receipts are allowable under federal law;

(b) The Authority shall complete an annual audit and reconciliation process within a nine-month period.

History

Statutory/Other Authority: ORS 413.234
Statutes/Other Implemented: ORS 413.234
DMAP 82-2025, amend filed 11/20/2025, effective 11/20/2025
DMAP 47-2025, temporary amend filed 06/02/2025, effective 06/02/2025 through 11/28/2025
DMAP 50-2023, adopt filed 06/30/2023, effective 07/01/2023

Or. Admin. R. 410-136-3373 Ground Emergency Medical Transportation - Emergency Medical Services Transport Private Provider Program - Quality Assurance Fee Requirements and Qualifications

(1) Quality Assurance Fee (QAF) assessment for the Ground Emergency Medical Transportation (GEMT) Emergency Medical Services Transport (EMST) private provider program:

(a) The amount of the QAF is assessed at least annually;

(b) The amount of the QAF is five percent (5%) of the gross receipts for the 12-month period for the calendar year. The amount of the QAF collected in calendar year 2022 or until the Coordinated Care Organizations (CCO) portion of the program is established will be less than the 5% to only account for the Fee for Service portion of the total transports. Any projections must be based on the data reported in the data request template;

(c) The eligible GEMT EMST private provider shall file the data request template form approved by the Authority on or before the 45th day following the term in which the assessment is due.

(A)The QAF payment shall be paid at the same time required for filing the data request template form.

(B) The GEMT EMST private provider shall provide all information required on the data request template form when due.

(d) GEMT EMST private provider shall report the data in the data request template form five business days after the date upon which the report is due. The Authority shall notify qualified providers not less than thirty days prior to the due date. After sending written notice to GEMT EMST private provider, the Authority may impose a penalty of $100 per day against GEMTEMST private provider for every day that the report is overdue. Any funds resulting from the penalty imposed under this section shall be deposited in the General Fund to be available for general governmental purposes; and

(e) All QAFs and interest collected shall be deposited into the Emergency Medical Services Fund established.

(2) QAF Penalties, Interest, and Fees:

(a) The Authority has the right to assess interest on QAF’s not paid by the due date at ten percent (10%), beginning on the day after the date the payment was due;

(b) The Authority has the right to assess a penalty equal to the interest charged under paragraph (a) of this subsection for each month for which the payment is more than sixty days overdue;

(c) The Authority shall deduct the amount of any unpaid fee, interest or penalty assessed under this section from any add on amount owed to the GEMT EMST private provider until the full amount of the fee, interest or penalty is recovered.

(A) The Authority may not make a deduction pursuant to this paragraph until after the Authority gives the GEMT EMST private provider written notification;

(B) The Authority may permit the amount owed to be deducted over a period of time that takes into account the financial condition of the GEMT EMST private provider.

(d) The Authority may waive a portion of or all interest or penalties, or both, assessed under this section if the Authority determines that the imposition of the full amount of the QAF in accordance with the due dates established under this section will impose an undue financial hardship on the GEMT EMST private provider. The waiver must be conditioned on the GEMT EMST private provider’s agreement to pay the QAF on an alternative schedule developed by the Authority;

(e) In the event of a merger, acquisition or similar transaction involving the GEMTEMST private provider that has outstanding QAFs, interest or penalties due, the successor GEMT EMST private provider is responsible for paying to the Authority the full amount of outstanding QAFs, interest and penalties that are due on the effective date of the merger, acquisition or transaction.

(3) Data Request Template Form:

(a) The Authority shall approve the data request template form for an eligible GEMT EMST private provider to report the data necessary to administer the QAF, including information about the portion of funds that the GEMT EMST private provider used to increase wages and benefits for employees, and may require a certification by each GEMT EMST private provider under penalty of perjury of the truth of the data reported under this section;

(b) The Authority requires GEMT EMST private provider to report the number of emergency medical services transports it provided in each 12-month period, by insurance payer type;

(d) Requires GEMT EMST private provider to report to the Authority the provider’s costs for GEMT emergency medical service transports.

History

Statutory/Other Authority: ORS 413.234
Statutes/Other Implemented: ORS 413.234
DMAP 50-2023, adopt filed 06/30/2023, effective 07/01/2023

Or. Admin. R. 410-136-3374 Ground Emergency Medical Transportation – Emergency Medical Services Transportation Private Provider Program - Coordinated Care Organizations Requirements and Payment Processing

(1) Definitions:

(a) “Coordinated Care Organization” has the meaning defined in OAR 410-141-3500;

(b) “Eligible Emergency Medical Services Provider” means an EMS provider that meets all the eligibility requirements described in (section B) below. A nonfederal or nonpublic entity that:

(A) Employs individuals who are licensed by the Oregon Health Authority under ORS chapter 682 to provide emergency medical services; and

(B) Contracts with a local government pursuant to a plan described in ORS 682.062.

(c) “Emergency Medical Services” means the act of transporting an individual by ground from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the individual, as well as provide advanced, limited-advanced, and basic life support services provided by Eligible Emergency Medical Services Provider before or during the act of transportation. This includes to assess, treat, and stabilize the individual’s medical condition; or prepare and transport the individual to a medical facility;

(d) “Emergency Medical Services Transport” means an emergency medical services provider’s evaluation of an individual experiencing a medical emergency and the transportation of the individual to the nearest medical facility capable of meeting the needs of the individual. For the purposes of this state plan, EMS air transports are excluded;

(e) “Managed Care Entity” has the meaning defined in OAR 410-141-3500;

(f) "Supplemental Payment" means a payment amount set by the Authority for each approved procedure code to supplement allowable costs for EMST services;

(g) "§438.6(c) Preprint" means a 42 CFR §438.6(c) Preprint approved by U.S. Department of Health and Human Services CMS for Qualified Directed Payments to GEMT Providers for GEMT Services rendered during the applicable CCO contract rating period.

(2) GEMT EMST Private Provider Eligibility Requirements. To be eligible for supplemental payments, GEMT EMST private providers shall meet the following requirements:

(a) Be enrolled as an Oregon Health Plan Medicaid provider;

(b) Provide ground emergency medical transport services to Medicaid recipients;

(d) Be a participating provider having a contractual agreement with a CCO on the date of GEMT EMST services.

(3) Supplemental Payment Process:

(a) GEMTEMST private providers may participate in the GEMT EMST private provider program described in this rule if the GEMT EMST provider is a participating provider in accordance with OAR 410-141-3500 on the date of service during the approved service period. OHA will apply the supplemental payment only to GEMT EMST private provider services rendered to CCO Medicaid members by eligible GEMT EMST Private Providers on or after January 1, 2024;

(b) The GEMT EMST Private Provider Program is for supplemental payments made by the Authority to CCOs for GEMT EMST private providers’ qualifying services when rendered by GEMT EMST private providers for the approved service period;

(c) In accordance with 42 CFR §438.6(c)(2)(i)(A), the supplemental payments are based on the federal match of the GEMT EMST private providers Quality Assurance Fee (QAF) defined in OAR 410-136-3373;

(d) The Authority shall pay any federal financial participation received from CMS, for qualifying GEMT EMST services, to the CCO;

(e) The CCO shall increase, by the same amount, the amount of reimbursement paid to the appropriate GEMT EMST private provider;

(f) The non-federal share portion of the supplemental payment is contributed by GEMT EMST private providers only;

(g) The GEMT EMST private provider shall agree to pay a fee to reimburse the Authority for the costs of administering the program;

(h) The Authority may adjust the amount of add on payments based on the costs to administer the program or any penalties or interest owed.

(4) Reporting and Billing Processes:

(a) The Authority shall provide the CCO with the calculation of the federal match determined by the Data Request Template described in OAR 410-136-3373;

(b) Payment by the CCO to participating providers for qualifying GEMT EMST services shall be at least annually.

(5) Quality Measurement:

(a) In accordance with 42 CFR §438.6(c)(2)(i)(C), this payment arrangement must advance at least one of the goals and objectives in Oregon's Medicaid quality strategy required per 42 CFR §438.340; and the Authority shall review progress on the advancement of the state's goal(s) and objective(s) in the quality strategy identified in this section;

(b) GEMT EMST private providers shall submit the quality measurement data specified in the §438.6(c) Preprint.

(6) Authority Responsibilities:

(a) The Authority shall apply for program authorization through a §438.6(c) Preprint for each calendar year;

(b) The Authority shall make a supplemental payment only if the GEMT EMST private provider meets criteria established by the Authority for the GEMT EMST CCO supplemental payment program in accordance with applicable federal requirements approved by CMS for the applicable program year;

(c) The Authority shall make a supplemental payment consistent with §438.6(c) Preprint approved with CMS for qualified transports described in OAR 410-136-3372;

(d) Upon receipt of an acceptable funds transfer from GEMT EMST private provider, the Authority shall verify data received and draw the federal funds in an amount determined to match the state portion.

History

Statutory/Other Authority: ORS 413.234
Statutes/Other Implemented: ORS 413.234
DMAP 82-2025, amend filed 11/20/2025, effective 11/20/2025
DMAP 47-2025, temporary amend filed 06/02/2025, effective 06/02/2025 through 11/28/2025
DMAP 50-2023, adopt filed 06/30/2023, effective 07/01/2023

Division 138 TARGETED CASE MANAGEMENT

Or. Admin. R. 410-138-0000 Targeted Case Management Definitions

The following definitions apply to OAR 410-138-0000 through 410-138-0390:

(1) “Assessment” means the act of gathering information and reviewing historical and existing records of an eligible client in a target group to determine the need for medical, educational, social, or other services. To perform a complete assessment, the case manager shall gather information from family members, medical providers, social workers, and educators, if necessary.

(2) “Care Plan” means a Targeted Case Management (TCM) Care Plan that is a multidisciplinary plan that contains a set of goals and actions required to address the medical, social, educational, and other service needs of the eligible client based on the information collected through an assessment or periodic reassessment.

(3) “Case Management” means services furnished by a case manager to assist individuals eligible under the Medicaid State Plan Amendment (SPA) in gaining access to and effectively using needed medical, social, educational, and other services (such as housing or transportation) in accordance with 42 CFR 441.18. See also the definition for Targeted Case Management.

(4) “Centers for Medicare and Medicaid Services (CMS)” means the federal agency under the U.S. Department of Health and Human Services that provides the federal funding for Medicaid and the Children’s Health Insurance Program (CHIP).

(5) “Children and Youth with Special Health Care Needs (CYSHCN)” means those children and youth who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

(6) “Department” means the Department of Human Services (Department).

(7) “Division” means the Oregon Health Authority’s Medicaid Division.

(8) “Duplicate Payment” means more than one payment made for the same services to meet the same need for the same client at the same point in time.

(9) “Eligible Client” means an individual who is found eligible for Medicaid or the Children’s Health Insurance Program (CHIP) by the Oregon Health Authority (Authority) and eligible for case management services (including TCM services) as defined in the Medicaid State Plan at the time the services are furnished.

(10) “Federal Financial Participation (FFP)” means the portion paid by the federal government to states for their share of expenditures for providing Medicaid services. FFP was created as part of the Title XIX, Social Security Act of 1965. There are two objectives that permit claims under FFP. They are:

(a) To assist individuals eligible for Medicaid to enroll in the Medicaid program; and

(b) To assist individuals on Medicaid to access Medicaid providers and services. The second objective involves TCM.

(11) “Federal Medical Assistance Percentage (FMAP)” means the percentage of federal matching dollars available to a state to provide Medicaid services. The FMAP is calculated annually based on a three-year average of state per capita personal income compared to the national average. The formula is designed to provide a higher federal matching rate to states with lower per capital income. No state receives less than 50 percent or more than 83 percent.

(12) “Medical Assistance Program” means a program administered by the Division that provides and pays for health services for eligible Oregonians. The Medical Assistance Program includes TCM services provided to clients eligible under the Oregon Health Plan (OHP) Title XIX and the Children’s Health Insurance Program (CHIP) Title XXI.

(13) “Monitoring” means ongoing face-to-face or other contact to conduct follow-up activities with the participating eligible client or the client’s health care decision makers, family members, providers, or other entities or individuals when the purpose of the contact is directly related to managing the eligible client’s care to ensure the care plan is effectively implemented.

(14) “Oregon Health Plan (OHP)” means the Medicaid program in Oregon that is known as the OHP and governed by a series of laws passed by the Oregon Legislature with the intention of providing universal access to healthcare to Oregonians. OHP is also governed by many federal laws.

(15) “Perinatal (for the purpose of the State Plan amendment for Public Health Nurse Home Visiting, Babies First!, CaCoon, and Nurse-Family Partnership TCM)” means the period inclusive of pregnancy through two years postpartum.

(16) “Reassessment” means periodically re-evaluating the eligible client to determine whether or not medical, social, educational, or other services continue to be adequate to meet the goals and objectives identified in the care plan. Reassessment decisions include those to continue, change, or terminate TCM services. A reassessment shall be conducted at least annually or more frequently if changes occur in an eligible client’s condition, or when resources are inadequate, or the service delivery system is non-responsive to meet the client’s identified service needs.

(17) “Reentry Targeted Case Management (also known as Targeted Case Management Services For Eligible Juveniles)” refers to the targeted case management services that will be provided as part of the Reentry FCAA Services to FCAA-Covered Youth as defined in OAR 410-155-0000 and OAR 410-155-0010.

(18) “Referral” means performing activities such as scheduling appointments that link the eligible client with medical, social, or educational providers, or other programs and services, and follow-up and documentation of services obtained.

(19) “Targeted Case Management (TCM) Services” means case management services furnished to a specific target group of eligible clients under the Medicaid State Plan to gain access to needed medical, social, educational, and other services (such as housing or transportation).

(20) “Unit of Government” means a city, a county, a special purpose district, or other governmental unit in the state.

(21) “Cost-sharing” means the Federal Financial Participation (FFP) matching program in which the TCM provider as a public entity, unit of government, must pay the non-federal matching share of the amount of the TCM claims.

(22) “Newborn Nurse Home Visiting Program (NNHV)” has the meaning described in OAR 333-006-0010. The program provides services to Medicaid-eligible newborns and their families. The program is governed by Public Health, Division 6 OAR 333-006-0000 to 333-006-333-006-0160. “Newborn Nurse Home Visiting Program” and “Universally Offered Newborn Nurse Home Visiting Program” can be used synonymously. Family Connects Oregon is the model being used to deliver the Newborn Nurse Home Visiting Program and can be used synonymously. NNHV is exempt from cost-sharing requirements.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022
DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04
HR 20-1992, f. & cert. ef. 7-1-92

Or. Admin. R. 410-138-0005 Payment for Targeted Case Management Services Eligible for Federal Financial Participation

(1) This rule is to be used in conjunction with Targeted Case Management (TCM) rules OAR 410-138-0000 through 410-138-0009 and 410-138-0390 and the Division’s General Rules chapter 410, division 120.

(2) TCM provider organizations providing TCM services, as defined in Section 1915(g) of the Social Security Act, that have been authorized under these rules, are eligible to participate in a cost sharing (Federal Financial Participation (FFP) matching) program. The rules in this Chapter 410, Division 138 have been designed to assist TCM provider organizations with obtaining the federal funds that are available to be matched with the non-federal fund contribution requirement.

(3) Providers of Tribal TCM, and TCM provided by the Newborn Nurse Home Visiting Program are exempt from cost-sharing requirements to pay non-federal matching funds.

(4) Payment shall be made to the TCM provider enrolled with the Authority as a unit of government provider meeting the requirements set forth in the provider enrollment agreement.

(5) Signing the provider enrollment agreement sets forth the relationship between the State of Oregon, the Authority, and the TCM provider and constitutes agreement by the TCM provider to comply with all applicable Authority rules and federal and state laws and regulations.

(6) The TCM provider shall bill according to administrative rules in chapter 410, division 138 and the TCM supplemental information. Payments shall be made using the Medicaid Management Information System (MMIS), and the TCM provider shall retain the full payment for covered services provided. The TCM provider shall have a Trading Partner Agreement with the Authority prior to submission of electronic transactions.

(7) Except for the TCM providers identified as exempt from cost-sharing requirements (which are identified in section (3) above this rule), a TCM provider that is public entity, unit of government, shall pay the non-federal matching share of the amount of the TCM claims, calculated using the Federal Medical Assistance Percentage (FMAP) rates in effect during the quarter when the TCM claims will be paid:

(a) The TCM provider's non-federal matching share means the public funds share of the Medicaid payment amount. Pursuant to the Social Security Act, 42 CFR 433.51, public funds may be considered as the state's share in claiming federal financial participation, if the public funds meet the following conditions:

(A) The public funds are transferred to the Authority from public entities that are units of government;

(B) The public funds are not federal funds, or they are federal funds authorized by federal law to be used to match other federal funds; and

(b) The unit of government TCM provider shall pay the non-federal matching share to the Authority in accordance with OAR 410-120-0035.

(8) Before the Authority pays for TCM claims, the Authority shall receive the corresponding local match payment as described in this rule. Failure to timely pay the non-federal matching funds to the Authority will delay payment.

(9) The Authority shall not be financially responsible for payment of any claim that CMS disallows under the Medicaid program. If the Authority has previously paid the TCM provider for any claim, which CMS disallows, the TCM provider shall reimburse the Authority the amount of the claim that the Authority has paid to the TCM provider, less any amount previously paid by the unit of government TCM provider to the Authority for the non-federal match portion for that claim.

(10) Providers shall only bill Medicaid for allowable activities in the TCM program that assist individuals eligible under the Medicaid State Plan to gain access to needed medical, social, educational, and other services. One or more of the following allowable activities shall occur before billing:

(a) Assessment;

(b) Development of a care plan;

(d) Monitoring and follow up.

(11) TCM claims may not duplicate payments made to:

(a) Public agencies or private entities for any other case management activities or direct services provided under the State Plan or OHP, through fee for service, managed care, or other contractual arrangement, that meet the same need for the same client at the same point in time;

(b) A TCM provider by program authorities under different funding authority than OHP, including but not limited to other public health funding;

(c) A TCM provider for administrative expenditures reimbursed under agreement with the Authority or any other program or funding source.

(12) Medicaid is only liable for the cost of otherwise allowable case management services if there are no other third parties liable to pay. However, while schools are legally liable to provide IDEA-related health services at no cost to eligible children, Medicaid reimbursement is available for these services because section 1903(c) of the Act requires Medicaid to be primary to the U.S. Department of Education for payment for covered Medicaid services furnished to a child with a disability. These services may include health services included in a child’s Individualized Education Program (IEP) or Individual Family Service Plan (IFSP) under the IDEA. Payment for those services that are included in the IEP or IFSP may not be available when those services are not covered Medicaid services.

(13) The Authority’s acceptance of cost data provided by provider organizations for the purpose of establishing rates paid for TCM services does not imply or validate the accuracy of the cost data provided.

(14) Reimbursement is subject to all rules and laws pertaining to federal financial participation.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 32-2025, amend filed 03/19/2025, effective 03/19/2025
DMAP 129-2024, temporary amend filed 10/22/2024, effective 10/22/2024 through 04/19/2025
DMAP 86-2024, temporary amend filed 04/25/2024, effective 04/25/2024 through 10/21/2024
DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022
DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09

Or. Admin. R. 410-138-0007 Targeted Case Management — Covered Services

(1) Targeted case management (TCM) services shall be furnished only to assist individuals eligible under the Medicaid State Plan in gaining access to and effectively using needed medical, social, educational, and other services (such as housing or transportation) in accordance with 42 CFR 441.18.

(2) TCM services billed to Medicaid shall be for allowable activities and include one or more of the following components:

(a) Assessment of an eligible client in the target group to determine the need for medical, educational, social, or other services as follows:

(A) Taking client history;

(B) Identifying the needs of the client, and completing related documentation;

(C) Gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the eligible client;

(D) Periodically reassessing a client to determine if the client's needs or preferences have changed. A reassessment shall be conducted at least annually or more frequently if changes occur in the client’s condition;

(b) Development of a care plan based on the information collected through the assessment or periodic reassessment, specifying the goals and actions to address the medical, social, educational, and other services needed by the eligible client. This may include:

(A) Active participation of the eligible client in the target group; or

(B) Working with the eligible client or the eligible client’s authorized health care decision maker and others to develop goals and identify a course of action to respond to the assessed needs of the eligible client;

(A) Scheduling appointments for the eligible client in the target group to obtain needed services; and

(B) Activities that help link the eligible client with medical, social, or educational providers, or other programs and services (e.g., food vouchers, transportation, child care, or housing assistance) that address identified needs and achieve goals specified in the care plan. The case management referral activity is completed once the referral and linkage have been made;

(d) Monitoring or ongoing face-to-face or other contact:

(A) Monitoring and follow-up activities include activities and contacts:

(i) To ensure the care plan is effectively implemented;

(ii) To help determine if the services are being furnished in accordance with the eligible client’s care plan;

(iii) To determine whether the care plan adequately addresses the needs of the eligible client in the target group;

(iv) To adjust the care plan to meet changes in the needs or status of the eligible client.

(B) Monitoring activities may include contacts with:

(i) The participating eligible client in the target group;

(ii) The eligible client’s healthcare decision makers, family members, providers, or other entities or individuals when the purpose of the contact is directly related to the management of the eligible client’s care.

(3) TCM services billed to Medicaid shall be documented in the client’s case records for all client’s receiving case management. The documentation shall include:

(a) The client’s name;

(b) The dates of the case management services;

(d) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved;

(e) Whether the client has declined services in the care plan;

(f) The need for, and occurrences of, coordination with other case managers;

(g) A timeline for obtaining needed services;

(h) A timeline for reevaluation of the plan.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09

Or. Admin. R. 410-138-0009 Targeted Case Management — Services Not Covered

Targeted Case Management (TCM) services do not cover:

(1) Direct delivery of an underlying medical, educational, social, or other service to which the eligible client has been referred.

(2) Providing transportation to a service to which an eligible client is referred.

(3) Escorting an eligible client to a service.

(4) Providing child care so that an eligible client may access a service.

(5) Contacts with individuals who are not categorically eligible for Medicaid or who are categorically eligible for Medicaid but not included in the eligible target population when those contacts relate directly to the identification and management of the non-eligible or non-targeted individual’s needs and care.

(6) Assisting an individual who has not yet been determined eligible for Medicaid to apply for or obtain eligibility.

(7) TCM services provided to an individual if the services are case management services funded by Title IV-E or Title XX of the Social Security Act, or federal or state funded parole and probation, or juvenile justice programs.

(8) Activities for which third parties are liable to pay.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09

Or. Admin. R. 410-138-0020 Targeted Case Management Programs

(1) This rule includes services in the State Plan for Targeted Case Management.

(2) TCM programs include the following:

(a) Human Immunodeficiency Virus (HIV);

(b) Public Health Nurse Home Visiting programs including, Babies First!, CaCoon, Newborn Nurse Home Visiting and Nurse-Family Partnership;

(d) Federally Recognized Tribal Governments.

(e) Oregon Youth Authority (OYA) Targeted Case Management Program

(3) With the exception of the Newborn Nurse Home Visiting program, the TCM Programs are medical assistance programs operated by public health authorities, unit of government providers, or Federally Recognized Tribal Governments in Oregon who are enrolled as TCM providers with the Authority. Participation by providers is voluntary and subject to approval by the Authority and CMS. With the exception of the Federally Recognized Tribal Governments TCM programs and the Newborn Nurse Home Visiting Program, the TCM programs authorized under these rules are cost-sharing (Federal Financial Participation (FFP) matching) programs in which the public fund agency, public entity, unit of government, shall pay the non-federal matching share of the amount of the TCM claims.

(4) The Public Fund Agency may contract TCM services provided by a Local Public Health Authority or other public or private agency if the public fund agency’s obligations for providing payment for the non-federal share for services provided and billed to Medicaid are met in compliance with 42 CFR 433.51 and the TCM services are provided by an enrolled Medicaid TCM provider who will receive and retain 100 percent of the TCM payments. See OAR 410-138-0005 (Payment for Targeted Case Management Services Eligible for Federal Financial Participation).

(5) Federally Recognized Tribal Governments TCM services authorized under these rules provided to tribal members (American Indian/Alaska Native) at an Indian Health Service (IHS/638) facility operated by the Indian Health Service, by an Indian tribe or tribal organization are reimbursed at 100 percent by Title XIX (Medicaid) and Title XXI Children’s Health Insurance Program (CHIP). TCM services provided by IHS/638 facilities to non-tribal American Indian/Alaska Native members shall be reimbursed at the applicable FMAP rate.

(6) The Authority may not authorize services or reimbursement for direct care as part of any TCM activity. The following are TCM programs and services:

(a) The TCM HIV program improves access to needed medical and non-medical services, which address physical, psychosocial, nutritional, educational, and other services for Medicaid categorically eligible clients with symptomatic or asymptomatic HIV disease. Home visits constitute an integral part of the delivery of TCM services, provided by a TCM HIV case manager consistent with these rules. Without TCM case management services, an eligible client’s ability to remain safely in their home may be at risk;

(b) The TCM Public Health Nurse Home Visiting Programs, Babies First!, CaCoon, Newborn Nurse Home Visiting and Nurse-Family Partnership improve access to needed medical and non-medical services that address medical, social, educational, and other services:

(A) The Babies First!, and Nurse-Family Partnership programs include Medicaid eligible perinatal people, eligible infants and children through four years of age who have one or more risk factors for poor perinatal, birth, and other poor health outcomes. TCM services may also be provided to a parent or other caretaker relative of the eligible child. See Table 1 and 2 Risk Criteria as outlined in OAR 410-138-0040 risk criteria;

(B) The CaCoon program shall be provided to Medicaid eligible Children and Youth with Special Health Care Needs (CYSHCN), up to age 21, who have one or more diagnosis. TCM services may also be provided to a parent or other caretaker relative of the eligible child. See Table 1 and 2 as outlined in OAR 410-138-0040 risk criteria;

(C) NNHV may be provided to Medicaid eligible infants 0 through 6 months of age. As part of a phased implementation services may be provided in the following counties: Lincoln, Benton, Crook, Deschutes, Gilliam, Hood River, Jefferson, Linn, Malheur, Wasco, Washington, Wheeler, Sherman, Baker, Clatsop, Marion, Lane, Polk, Yamhill, Douglas, Multnomah and Coos.

(D) Home visits constitute a significant part of the delivery of targeted case management services, provided by a Public Health Nurse Home Visiting (Babies First!, CaCoon, NNHV and Nurse Family Partnership) targeted case manager consistent with these rules. All providers for Babies First!, CaCoon, NNHV and Nurse-Family Partnership TCM programs shall follow a case management plan developed by the nurse.

(c) Reentry Targeted Case Management services are provided to FCAA-Covered Youth as part of Reentry FCAA Services. The Reentry FCAA Service requirements are described in OAR 410-155-0000, and OAR 410-155-0010.

(d) The TCM Federally Recognized Tribal Government program improves access to needed medical and non-medical services, which address health, psychosocial, economic, educational, nutritional, and other services for Medicaid categorically eligible tribal members served by tribal programs, provided by an enrolled tribal TCM provider consistent with these rules. The target group includes those members receiving elder care; individuals with diabetes; children and adults with health and social service care needs, and pregnant women.

(e) The OYA provides TCM services to Medicaid-eligible youth under age 21 who are residing in independent living situations, in-home settings, foster homes, group homes, or residential care facilities under OYA's responsibility—including those transitioning to the community and those receiving services for up to 180 consecutive days during covered institutional stays—as described in Oregon’s Title XIX State Plan (Transmittal 25-0018), effective July 1, 2025.

(7) Refer to the State Plan Amendments for participating counties for each TCM program. The State Plan Amendments are located at http://www.oregon.gov/OHA/HPA/HP/Pages/Medicaid-CHIP-State-Plans.aspx.

(8) Provision of any TCM Program services may not restrict an eligible client’s choice of providers, in accordance with 42 CFR 441.18(a):

(a) Eligible clients shall have free choice of available TCM Program service providers or other TCM service providers available to the eligible client, subject to the Social Security Act, 42 USC 1396n and 42 CFR 441.18(b);

(b) Eligible clients shall have free choice of the providers of other medical care within their benefit package of covered services.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 61-2025, amend filed 08/14/2025, effective 08/18/2025
DMAP 38-2025, temporary amend filed 04/11/2025, effective 04/11/2025 through 09/05/2025
DMAP 31-2025, temporary amend filed 03/10/2025, effective 03/10/2025 through 09/05/2025
DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022
DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022
DMAP 24-2021, amend filed 06/22/2021, effective 06/29/2021
DMAP 68-2020, temporary amend filed 12/28/2020, effective 01/01/2021 through 06/29/2021
DMAP 13-2020, amend filed 03/24/2020, effective 03/27/2020
DMAP 39-2019, temporary amend filed 09/30/2019, effective 10/01/2019 through 03/28/2020
DMAP 54-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04
HR 20-1992, f. & cert. ef. 7-1-92

Or. Admin. R. 410-138-0040 Targeted Case Management Babies First!, CaCoon, and Nurse-Family Partnership Program Risk Criteria

(1) This rule is in effect for services approved by CMS effective for services rendered beginning January 1, 2017, and sets forth the criteria for risk factors for the TCM Babies First!, CaCoon, and Nurse-Family Partnership programs to include perinatal and parental eligibility criteria in Table 1 and risk factors for Babies First!, CaCoon and Nurse Family Partnership TCM infant and children eligibility criteria and diagnosis in Table 2.

(2) Table 1 risk criteria for TCM perinatal and parental eligibility and Table 2 risk criteria for TCM infant and children eligibility and diagnosis criteria become effective January 1, 2017, and may be obtained by clicking on the PDF copy.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022
DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022
DMAP 13-2020, amend filed 03/24/2020, effective 03/27/2020
DMAP 48-2017, amend filed 11/07/2017, effective 11/07/2017
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04
HR 37-1994, f. 12-30-94, cert. ef. 1-1-95
HR 20-1992, f. & cert. ef. 7-1-92

Or. Admin. R. 410-138-0060 Targeted Case Management Program — Provider Requirements

(1) TCM Public Health Nurse Home Visiting (Babies First!, CaCoon, and Nurse-Family Partnership) targeted case managers may be an employee of a Local Public Health Authority or other public or private agency contracted by a Local Public Health Authority with the demonstrated ability to meet all state and federal laws governing the participation of providers in the state Medicaid program and the ability to provide data to the Family and Child Health (FCH) Data System.

(2) TCM services provided under the Universally Offered Newborn Nurse Home Visiting Program as defined in Public Health 333, Division 6 Newborn Nurse Home Visiting must be provided by certified providers.

(3) TCM Federally Recognized Tribal Governments providers shall be Indian Health Services/638 facilities.

(4) All providers shall demonstrate the ability to provide all core elements of case management services including:

(a) Comprehensive assessment, which may include triage and environmental assessment of client needs;

(b) Reassessment of the client’s status and needs annually or more frequently with a significant change in the client’s condition;

(d) Referral and linking/coordination of services;

(e) Ongoing monitoring and follow-up of referral and related services;

(f) A financial management capacity and system that provides documentation of services and costs and provides computerized tracking and monitoring to assure adequate follow-up and avoid duplication.

(5) Except for Federally Recognized Tribal Governments and the Newborn Nurse Home Visiting Program, the TCM provider shall provide the non-federal matching share from public funds in compliance with OAR 410-138-0005.

(6) If the provider is a subcontractor of a governmental entity, the governmental entity shall make the non-federal matching share with public fund payments in compliance with OAR 410-138-0005.

(7) All program providers shall demonstrate the following TCM experience and capacity:

(a) Understanding and knowledge of local and state resources and services available to the target population;

(b) Demonstrated case management experience in coordinating and linking community resources as required by the target population;

(d) An administrative capacity to ensure quality of services in accordance with state and federal requirements;

(e) A financial management capacity and system that provides documentation of services and costs;

(f) Capacity to document and maintain client case records in accordance with state and federal requirements, including requirement for recordkeeping on OAR 410-138-0007 and 410-120-1360; confidentiality requirements in ORS 192.518–192.524,179.505 and 411.320; and HIPAA Privacy requirements applicable to case management services;

(g) A sufficient number of staff to meet the case management service needs of the target population;

(h) Demonstrated ability to meet all state and federal laws governing the participation of providers in the state Medicaid program; and

(i) Enrolled as a TCM provider with the Authority and meeting the requirements set forth in the provider enrollment agreement.

(8) The TCM case managers for the Public Health Nurse Home Visiting, Babies First!, CaCoon, and Nurse-Family Partnership programs:

(a) May be an employee of a local public health authority or other public or private agency contracted by a Local Public Health Authority;

(b) Shall be a licensed registered nurse with experience in community health, public health, or child health nursing; and

(c) May be a community health worker working under the plan developed by a licensed registered nurse. The minimum qualifications of the Community Health Workers are as follows:

(A) High School Graduate or GED with additional course work in human growth and development, health occupations, or health education; and

(B) Two years’ experience in public health, mental health, or alcohol drug treatment settings; or

(C) Any satisfactory combination of experience and training that demonstrates the ability to perform case management duties;

(D) The case manager shall work under the policies, procedures, and protocols of the state FCH Section.

(9) The TCM case managers for the Newborn Nurse Home Visiting Program must be a licensed registered nurse and an employee of a certified NNHV provider as defined in Public Health 333, Division 6 Universally Offered Newborn Nurse Home Visiting Program. The case manager shall work under the policies, procedures, and protocols of the state FCH Section.

(10) TCM HIV providers shall have the financial management capacity and system that provides documentation of services and costs and is able to generate quarterly service utilization reports that can be used to monitor services rendered against claims submitted and paid. The service utilization reporting requirements are as follows:

(a) Report on the number of unduplicated clients receiving services during the reporting period;

(b) Report on the number of full time equivalent (FTE) case managers providing services during the reporting period; and

(c) Report on the number of distinct case management activities performed during the reporting period (Triage Assessments, Comprehensive Assessments, Re-Assessments, Care Plan Development, Referral and Related Services, and Monitoring Follow-Up) along with the total number of 15-minute increments associated with each activity category.

(11) TCM HIV case managers shall possess the following education and qualifications:

(a) A current active Oregon registered nurse (RN) license or Bachelor of Social Work, or other related health or human services degree from an accredited college or university; and

(b) Documented evidence of completing the Authority’s HIV Care and Treatment designated HIV Targeted Case Manager training and shall participate in the Authority’s on-going training for HIV targeted case managers. The training may either be provided by the Authority or be approved by the Authority and provided by the TCM provider organization.

(12) A Federally Recognized Tribal Governments TCM provider shall be an organization certified as meeting the following criteria:

(a) A minimum of three years’ experience of successful work with Native American children, families, and elders involving a demonstrated capacity to provide all core elements of tribal case management including: assessment, case planning, case plan implementation, case plan coordination, and case plan reassessment;

(b) A minimum of three years case management experience in coordinating and linking community medical, social, educational, or other resources as required by the target population;

(c) Administrative capacity to ensure quality of services in accordance with tribal, state, and federal requirements; and

(d) Evidence that the TCM organization is a federally recognized tribe located in the State of Oregon.

(13) The following are qualifications of Tribal Case Managers within provider organizations:

(a) Completion of training in a case management curriculum;

(b) Basic knowledge of behavior management techniques, family dynamics, child development, family counseling techniques, emotional and behavioral disorders, and issues around aging;

(c) Skill in interviewing to gather data and complete needs assessment in preparation of narratives/reports, in development of service plans, and in individual and group communication;

(d) Ability to learn and work with state, federal and tribal rules, laws and guidelines relating to Native American child, adult, and elder welfare and to gain knowledge about community resources and link tribal members with those resources;

(e) Knowledge and understanding of these rules and the applicable Medicaid State Plan Amendment.

(14) Providers delivering Reentry Targeted Case Management services as part of Reentry FCAA Services as described in OAR 410-155-0010 must meet the following requirements:

(a) Be a licensed practitioner working within the scope of practice as defined by state law, including but not limited to, a Physician as defined in ORS 677.010, a Nurse Practitioner licensed under ORS 678.375, a Registered Nurse licensed under ORS 678.021, 6780.040, 678.279 or 678.370; or

(b) Be a Behavioral Health Clinician as defined in ORS 414.025; or

(d) Be a Certified Alcohol and Drug Counselor (CADC), Certified Alcohol and Drug Counselor Candidate (CADC-R), or Certified Gambling Addiction Counselor (CGAC) as defined in OAR 309-083-0010; or

(e) Be a Master’s Social Worker licensed under ORS 675.533 or a board registered Baccalaureate Social Worker per ORS 675.523; or

(f) Possess certification through the Oregon Health Authority Office of Equity and Inclusion as a Traditional Health Worker and;

(A) Work under the supervision of a licensed clinician; or

(B) Are an employee of a CCO; or

(C) Are an employee of a Medicaid-enrolled public or private agency, inclusive of Local Public Health Authorities, with the demonstrated ability to meet all state and federal laws governing the participation of providers in the state Medicaid program.

(g) Work in compliance with Medicaid policies, procedures, and protocols as described in OAR 410-141-3510.

(15) Oregon Youth Authority TCM provider organization shall meet the following requirements:

(a) A minimum of three years of successful experience working with children and families—including demonstrated capacity in assessment, care planning, implementation, coordination, and reassessment.

(b) At least three years of experience coordinating community medical, social, educational, or other resources for the target population.

(d) Financial management systems sufficient to document services and associated costs.

(e) Recordkeeping systems consistent with state and federal requirements for individual case records.

(f) Demonstrated commitment to ensuring freedom of choice for eligible individuals, in accordance with 42 CFR 441.18(a)(1) and section 1902(a)(23) of the Social Security Act.

(16) Oregon Youth Authority TCM case managers shall meet the following requirements:

(a) Completion of case management training.

(b) Foundational knowledge in behavior management, family dynamics, child development, counseling, and emotional or behavioral disorders.

(c) Proficiency in interviewing, needs assessment, narrative/report writing, service planning, and both individual and group communication.

(d) Ability to navigate court systems, understand applicable rules and laws, and maintain familiarity with community resources.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022
DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022
DMAP 13-2020, amend filed 03/24/2020, effective 03/27/2020
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04
HR 37-1994, f. 12-30-94, cert. ef. 1-1-95
HR 20-1992, f. & cert. ef. 7-1-92

Or. Admin. R. 410-138-0080 Targeted Case Management Program Billing Policy

(1) Reimbursement is based on cost-based rate methodology and subject to all rules and laws pertaining to federal financial participation. The Authority’s acceptance of cost data provided by provider organizations for the purpose of establishing rates paid for TCM services does not imply or validate the accuracy of the cost data provided.

(2) The cost-based rate shall be derived by considering the following expenditures directly attributable to TCM staff:

(a) TCM staff salaries and other personnel expenses;

(b) Supervisory salaries and other personnel expenses;

(d) Services and supply expenses;

(e) Various overhead expenditures, if not already considered in the indirect rate.

(3) The Division shall accept a claim up to 12 months from the date of service. See provider rule OAR 410-120-1300 (Timely Submission of Claims).

(4) Providers shall only bill for allowable activities in the TCM programs that assist individuals eligible under the Medicaid State Plan to gain access to needed medical, social, educational, housing, environmental, and other services.

(5) The Division may not allow duplicate payments to other public agencies or private entities under other program authorities for TCM services under the eligible client’s care plan. Medical services shall be provided and billed separately from case management services. The Authority shall recover duplicate payments.

(6) The Division may not reimburse for TCM services if the services are case management services funded by Title IV-E or Title XX of the Social Security Act. These services shall be billed separately.

(7) Any place of service is valid.

(8) Prior authorization is not required.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08
OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04
HR 37-1994, f. 12-30-94, cert. ef. 1-1-95
HR 20-1992, f. & cert. ef. 7-1-92

Or. Admin. R. 410-138-0390 Targeted Case Management Retroactive Payments

(1) Providers may submit claims retroactively for services provided to the targeted populations described in OAR 410-138-0020(2) if the claims meet the following criteria:

(a) Services were provided less than 12 months prior to the date of first claim submission and were provided on or after the date indicated in the rule listed above and were allowable services in accordance with OAR 410-138-0007;

(b) The maximum number of units billed does not exceed the maximum allowed under each TCM program.

(c) The case manager was appropriately licensed or certified and met all current requirements for case managers at the time the service was provided, as described in the provider requirements rule OAR 410-138-0060 appropriate for the TCM program;

(d) Documentation regarding provider qualifications and the services that the provider retroactively claims shall have been available at the time the services were performed.

(2) The Division may not allow duplicate payments to be made to the same or different providers for the same service for the same client, nor will payment be allowed for services for which third parties are liable to pay (see also OAR 410-138-0005).

(3) Reimbursement is subject to all rules and laws pertaining to federal financial participation.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 21-2013, f. & cert. ef. 4-26-13
DMAP 48-2012(Temp), f. & cert. ef. 10-31-12 thru 4-28-13
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 34-2009(Temp), f. & cert. ef. 11-16-09 thru 5-1-10

Division 140 VISUAL SERVICES

Or. Admin. R. 410-140-0010 Definitions and Acronyms

(1) Aphakia is a condition in which the eye lens of one or both eyes are missing.

(2) Comorbidity has the meaning provided in OAR 410-141-3820 (10 & 11).

(3) Congenital aphakia is a congenital eye defect presenting at birth with no lens formation.

(4) Contractor is SWEEP Optical Laboratories, providing vision materials and supplies for OHP members with FFS coverage (refer to OAR 410-140-0400);

(5) “Coordinated Care Organization (CCO)” has the meaning as provided in OAR 410-141-3500. A CCO is a Managed Care Entity for its managed care contract(s) with the Authority, without regard to whether the contract(s) involves federal funds or state funds or both.

(6) “Covered Services” has the meaning as provided in OAR 410-120-0000.

(7) “Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services” means the federally mandated comprehensive and preventative child health program for individuals under the age of 21, under the Omnibus Budget Reconciliation Act of 1989 and Section 1905(r)(5) of the Social Security Act. Consistent with state and federal law and regulations, the OHP Dental Program ensures that all dentally necessary services and screenings are provided, either directly or through an Authority contracted MCE for EPSDT covered services (Chapter 410, Division 151).

(8) “Fraud” has the meaning as provided in OAR 410-120-0000.

(9) “Health Care Interpreter (HCI)” means an individual who has been approved and certified by the Authority under ORS 413.558 to accurately interpret oral statements and documents to a person with limited English proficiency or in sign language. Qualified Health Care Interpreter has the same meaning.

(10) Health Evidence Review Commission (HERC) has the meaning provided in OAR 410-120-0000.

(11) “Interpreter Services” means services available to those with Limited English Proficiency (LEP) as described in Title VI of the Civil Rights Act of 1964; Section 1557 of the Affordable Care Act; and ORS 413.550 for Meaningful Language Access Interpreter services may also be accessed for deaf or hard of hearing members to ensure effective communication, as required by the Americans with Disabilities Act. The interpreter shall be a certified or qualified health care interpreter (HCI).

(12) Keratoconus is an eye condition in which your cornea gets thinner and gradually bulges outward into a cone shape.

(13) Managed Care Entity (MCE) has the meaning provided in OAR 410-120-0000.

(14) “Medicaid Division” (Division) has the meaning as provided in OAR 410-120-0000 and is within the Authority. The Division is responsible for managing the Oregon Health Plan (OHP), which is Oregon’s Medicaid program.

(15) Ocular prosthesis has the meaning as provided in OAR 410-122-0010.

(16) Ophthalmologist is a specialist in the study and treatment of disorders and diseases of the eye;

(17) Optometrist has the meaning provided in OAR 410-120-0000;

(18) Optometric services has the meaning provided in OAR 410-120-0000;

(19) Oregon Health Authority (Authority) has the meaning provided in OAR 410-120-0000.

(20) Oregon Health Plan (OHP) has the meaning provided in OAR 410-120-0000 and OAR 410-141-3500.

(21) “Prescription” means the definition provided in OAR 410-121-0144.

(22) “Prioritized List of Health Services” (Prioritized list) means the comprehensive list of health services, ranked by priority. The Oregon Health Plan benefits are made from The List and determined by the Oregon Legislature.

(23) Pseudophakia is a term used for placing an artificial lens into the eye. Also referred to as intraocular, “fake lenses” or lens implants.

(24) Refraction determination is testing performed by an optometrist or ophthalmologist to determine refractive error in vision causing nearsightedness, farsightedness, or astigmatism.

(25) The Division of Medical Assistance Programs (Division) has the meaning provided in OAR 410-120-0000.

(26) Third-Party Liability (TPL) has the meaning provided in OAR 410-120-0000.

(27) “Vision Services” refer to services provided by an optometrist or ophthalmologist.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065, 414.025 & 414.075
DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024

Or. Admin. R. 410-140-0140 Vision Coverage

(1) The Division covers:

(a) Ocular prosthesis (e.g., artificial eye) and related services (OAR 410-122-0640).

(b) Reasonable services for diagnosing conditions, including the initial diagnosis of a condition that is below the funding line on the Prioritized list. When a diagnosis is established for a service, treatment, or item that falls below the funding line, the Division may not cover any other services related to the diagnosis unless the member meets the comorbidity rules (OAR 410-141-3820(10) & (11)).

(A) When therapy treatment pairs with a covered diagnosis on the Prioritized List; and

(B) Limited to six (6) sessions per calendar year (no PA required):

(i) The initial evaluation is included in the six (6) therapy sessions;

(ii) Additional therapy sessions require PA (OAR 410-140-0420);

(iii) Providers shall develop a therapy treatment plan and regimen that shall be taught to the member, family, foster parents, and caregiver during the therapy treatments. No extra treatments shall be authorized for teaching;

(iv) Therapy that can be provided by the member, family, foster parents, and caregiver is not a reimbursable service; and

(v) All vision therapy services including the initial evaluation shall be billed to the Division with the Current Procedural Terminology (CPT) code for orthoptic and pleoptic training.

(2) Division members are enrolled for covered health services to be delivered through one of the following means:

(a) Managed Care Entity (MCE) as defined in OAR 410-120-0000. Payment for all vision services provided to MCE members by ophthalmologists, optometrists, and opticians is a matter between the provider and the MCE;

(b) Fee-for-service (FFS):

(A) FFS members are not enrolled in an MCE and may receive vision services from any Division-enrolled provider that accepts FFS members subject to limitations and restrictions in the visual services program rules; and

(B) All claims must be billed directly to the Division.

(3) When a member has both Medicare and coverage through the Division, optometrists and ophthalmologists shall bill Medicare first for Medicare covered services.

(4) When a member has third party liability (TPL) and coverage through the Division, optometrists and ophthalmologists shall bill TPL first for TPL covered services.

(5) When an OHP member receives services on a FFS basis under the Division’s rules and has Medicare or TPL coverage:

(a) A provider may order visual materials from any visual materials supplier; and

(b) The Division does not require PA for Medicare or TPL covered services.

(6) Coverage for eligible adults (age 21 and older):

(a) One complete examination and determination of refractive state is limited to once every 24 months for non-pregnant members;

(b) One complete examination and determination of refractive state is limited to once (1) every 24 months for pregnant members and during the protected post-partum 12-month period (OAR 410-200-0135).

(c) Diagnostic evaluations and medical examinations are not limited if documentation in the physician's or optometrist's clinical record justifies the medical need for diagnosis;

(d) Ophthalmological intermediate and comprehensive exam services are not limited for allowable medical diagnosis;

(e) Visual services for the purpose of prescribing glasses or contact lenses and fitting fees are as follows:

(A) When determined necessary during a limited complete examination and determination of refractive state for pregnant members and during the protected post-partum 12-month period (OAR 410-200-0135).

(B) Non-pregnant adults are not covered, except when the member:

(i) Has a medical diagnosis of aphakia, pseudophakia, congenital aphakia, keratoconus; or

(ii) Lacks the natural lenses of the eye due to surgical removal (e.g., cataract extraction) or congenital absence; or

(iii) Has had a keratoplasty surgical procedure (e.g., corneal transplant) with limitations described in OAR 410-140-0160 (Contact Lens Services and Supplies).

(7) OHP Plus Children (birth through age 20):

(a) All ophthalmological examinations and vision services, including routine vision exams, fittings, repairs, and materials are covered when documentation in the clinical record justifies the medical need;

(b) The standard of care and expectation is that all comprehensive eye exams for children be dilated.

(c) With the diagnosis of Amblyopia, band-aid patches treatment shall be covered with a prescription. Quantity limit is sixty (60) per thirty (30) days.

(8) Refraction determination is not limited following a diagnosed medical condition (e.g., multiple sclerosis).

(9) The Division reimburses all covered surgical procedures as global packages, except when the surgeon codes the surgical procedure with a modifier indicating surgical procedure only, excluding post-operative care.

(10) The Division OHP vision benefit packages:

(a) For non-pregnant adults (age 21 and older), visual services and materials to diagnose and correct disorders of refraction and accommodation are covered only when the member:

(A) Has a covered medical diagnosis, following cataract surgery or a corneal lens transplant as described in OAR 410-140-0140; or

(B) Is in their protected post-partum 12-month period (see OAR 410-200-0135);

(b) For pregnant adult people (age 21 and older) other visual services are covered with limitations as described in these rules;

(c) For children (birth through age 20): Visual services are covered as described in this rule and without limitation when documentation in the clinical record justifies the medical need.

(11) Post-operative care includes all related follow-up visits and examinations provided within:

(a) Ninety (90) days following the date of major surgery; or

(b) Ten (10) days following the date of minor surgery; and

(c) Claims for evaluation and management services and ophthalmological examinations billed within the follow-up period shall be denied.

(12) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.075
DMAP 127-2024, amend filed 10/08/2024, effective 10/08/2024
DMAP 79-2024, minor correction filed 03/22/2024, effective 03/22/2024
DMAP 50-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 74-2022, amend filed 09/23/2022, effective 09/25/2022
DMAP 43-2022, temporary amend filed 03/29/2022, effective 04/01/2022 through 09/24/2022
DMAP 7-2016, f. 2-23-16, cert. ef. 3-1-16
DMAP 26-2014, f. 4-29-14, cert. ef. 5-8-14
DMAP 44-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 20-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 24-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 20-1999, f. & cert. ef. 4-1-99
HR 26-1996, f. 11-29-96, cert. ef. 12-1-96
HR 15-1996(Temp), f. & cert. ef. 7-1-96
HR 1-1996, f. 1-12-96, cert. ef. 1-15-96
HR 37-1992, f. & cert. ef. 12-18-92
HR 15-1992, f. & cert. ef. 6-1-92, Renumbered from 461-018-0220
AFS 75-1989, f. & cert. ef. 12-15-89, Renumbered from 461-018-0012
AFS 22-1987, f. 5-29-87, ef. 7-1-87
AFS 5-1985, f. & ef. 1-25-85
AFS 31-1984(Temp), f. 7-26-84, ef. 8-1-84
AFS 24-1984(Temp), f. & ef. 5-29-84
AFS 6-1984(Temp), f. 2-28-84, ef. 3-1-84

Or. Admin. R. 410-140-0160 Contact Lens Services and Supplies

(1) The following is general information regarding the Division’s contact lens services and supplies coverage for members who receive services on an FFS basis:

(a) The prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation, is only covered when provided by an optometrist or other qualified physician. Contact lens fitting by an independent technician in an optometry office is not a covered service; and

(b) Contact lenses shall be billed to the Division at the provider’s acquisition cost. Acquisition cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer or supplier plus any shipping fees for the item. Payment for contact lenses is the lesser of the Division fee schedule and acquisition cost.

(2) Coverage for eligible adults (age 21 or older):

(a) PA is required for contact lenses for adults (age 21 and older), except for a primary keratoconus diagnosis;

(b) Contact lenses for adults (age 21 and older) are covered only when one of the following conditions exists:

(A) Refractive error which is 9 diopters or greater in any meridian;

(B) Keratoconus;

(D) Irregular astigmatism;

(E) Aphakia; or

(F) Post keratoplasty (e.g., corneal transplant), when medically necessary and within one (1) year of procedure.

(c) Prescription and fitting of contact lenses is limited to once every twenty four (24) months. Replacement of contact lenses is limited to a total of two (2) contacts every twelve (12) months (or the equivalent in disposable lenses) and does not require PA.

(3) Coverage for Children (birth through age 20):

(a) Contact lenses for children are covered and are not limited when it is documented in the clinical record that glasses may not be worn for medical reasons, including, but not limited to:

(A) Refractive error which is 9 diopters or greater in any meridian;

(B) Keratoconus;

(D) Irregular astigmatism; or

(E) Aphakia.

(b) Replacement of contact lenses is covered when documented as medically appropriate in the clinical record and does not require PA.

(4) Contact lenses for treatment of disease or trauma (e.g., corneal bandage lens) are inclusive of the fitting. Follow up visits to determine eye health status may be separately reimbursed when the trauma or disease is clearly documented in the member record.

(5) An extra or spare pair of contacts is not covered.

(6) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 148-2024, minor correction filed 12/29/2024, effective 12/29/2024
DMAP 127-2024, amend filed 10/08/2024, effective 10/08/2024
DMAP 51-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 45-2021, amend filed 10/22/2021, effective 10/22/2021
DMAP 19-2021, temporary amend filed 05/13/2021, effective 05/13/2021 through 11/08/2021
DMAP 7-2016, f. 2-23-16, cert. ef. 3-1-16
DMAP 26-2014, f. 4-29-14, cert. ef. 5-8-14
DMAP 44-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 20-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 21-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 65-2004, f. 9-13-04, cert. ef. 10-1-04
OMAP 11-2002, f. & cert. ef. 4-1-02
OMAP 24-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 20-1999, f. & cert. ef. 4-1-99
HR 1-1996, f. 1-12-96, cert. ef. 1-15-96
HR 5-1995, f. & cert. ef. 3-1-95
HR 37-1992, f. & cert. ef. 12-18-92
HR 15-1992, f. & cert. ef. 6-1-92, Renumbered from 461-018-0230
AFS 75-1989, f. & cert. ef. 12-15-89

Or. Admin. R. 410-140-0200 Glasses

(1) The Division covers the fitting of glasses and the refitting and repair of glasses only when glasses and replacement parts are purchased from:

(a) The Division’s contractor;

(b) Any visual materials supplier when the member has primary Medicare coverage or Third Party Liability (TPL) coverage and the glasses were a Medicare-covered or TPL-covered benefit.

(2) The Division covers glasses for:

(a) Eligible adults (age 21 and older) once (1) every 24 months;

(b) Members once within 120 days following cataract surgery. When ordering glasses from contractor, the date of surgery must be listed on the order form;

(c) Eligible children (birth through age 20) without limitation when it is documented in the physician’s or optometrist's clinical record as medically appropriate.

(3) Fitting of glasses for:

(a) Eligible adults (age 21 years and older) is limited to once (1) every 24 months, except when dispensing glasses within 120 days of cataract surgery;

(b) Eligible children (birth through age 20) only when documented in the member's record as medically necessary and medically appropriate.

(4) Periodic adjustment of frames and tightening of screws is included in the dispensing fee and is not separately reimbursed.

(5) The Division accepts either the date of order or date of dispensing as the date of service on claims. Glasses must be dispensed prior to billing the Division, except under the following conditions:

(a) Death of the member prior to dispensing; or

(b) Member failure to pick up ordered glasses. Documentation in the member's record must show that the provider made serious efforts to contact the member.

(6) Providers must keep a copy of the delivery invoice included with all parts orders in the member's records or document the delivery invoice number in the member's records for all repair and refitting claims.

(7) Fitting of spectacle mounted low vision aids, single element systems, telescopic or other compound lens systems are not covered.

(8) All frames have a limited warranty. Check specific frame styles for time limits. All defective frames must be returned to the contractor.

(9) It is the provider’s responsibility to verify member eligibility and benefit coverage pursuant to OAR 410-120-1140, prior to submitting a visual materials order to SWEEP optical.

(10) If a member receives services under section (2)(b) of this rule:

(a) The Division may require a Prior Authorization (PA) for certain covered services or items before the service may be provided and before payment is made; and

(b) Providers needing materials and supplies are required to order those directly from SWEEP Optical, except when the OHP member has primary Medicare coverage or Third Party Liability (TPL) coverage (Refer to OAR 410-120-0000).

(11) Frames for display purposes may be purchased from the contractor for the same price as frames for glasses negotiated by the Oregon Department of Administrative Services:

(a) A case may not be provided with display frames; and

(b) Quantity, style, size, and color of frames must be specified in the order for display frames.

(12) Costs for the following are included in reimbursement for the lens and are not separately reimbursed by the Division:

(a) Scratch coating;

(b) Prism;

(d) Tracings.

(13) If a frame cannot be located in the contractor’s catalog at www.sweepoptical.com that meets the medical needs of the member:

(a) Providers shall contact contractor for assistance with locating a frame to meet the member’s need; and

(b) Frames not included in the contract between the Division and contractor may be purchased through contractor with PA.

(14) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 127-2024, amend filed 10/08/2024, effective 10/08/2024
DMAP 52-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 74-2022, amend filed 09/23/2022, effective 09/25/2022
DMAP 7-2016, f. 2-23-16, cert. ef. 3-1-16
DMAP 26-2014, f. 4-29-14, cert. ef. 5-8-14
DMAP 44-2009, f. 12-15-09, cert. ef. 1-1-10
OMAP 60-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 56-2002, f. & cert. ef. 10-1-02
OMAP 11-2002, f. & cert. ef. 4-1-02
HR 26-1996, f. 11-29-96, cert. ef. 12-1-96
HR 15-1996(Temp), f. & cert. ef. 7-1-96
HR 1-1996, f. 1-12-96, cert. ef. 1-15-96
HR 37-1992, f. & cert. ef. 12-18-92
HR 15-1992, f. & cert. ef. 6-1-92, Renumbered from 461-018-0250
AFS 75-1989, f. & cert. ef. 12-15-89

Or. Admin. R. 410-140-0400 Contractor Services

(1) The Division of Medical Assistance Programs (Division) contracts with SWEEP Optical Laboratories (also referred to herein as contractor) to provide vision materials and supplies. Providers needing materials and supplies must order those directly from the contractor, except when the Oregon Health Plan (OHP) member has primary Medicare coverage or Third Party Liability (TPL) coverage. See OAR 410-140-0080.

(2) The Division contracts with SWEEP Optical Laboratories (also referred to herein as contractor) to buy vision materials and supplies, excluding contact lenses. All frames, lenses, and miscellaneous items must be provided:

(a) Only by the contractor, unless the member has primary Medicare coverage or Third Party Liability (TPL) coverage; or

(b) By any visual materials supplier when the member has primary Medicare coverage for a Medicare covered item or TPL coverage for a TPL-covered item.

(3) The contractor’s responsibilities:

(a) Forward Division PA approval to the provider;

(b) Order specifications:

(A) The contractor shall provide the order as specified by the ordering provider;

(B) The contractor shall be responsible for all shipping and handling charges for shipments to the provider via United States mail or United Parcel Service for all returned orders that are not to the specifications of the order or that are damaged in shipping;

(C) The contractor may not accept initial orders via telephone. The contractor shall accept telephone calls or faxed messages regarding orders that are not made to specifications;

(D) When the contractor is notified of an item to be returned due to the item not being made to specifications in the original order, the contractor shall begin remaking the product as soon as they are notified, whether or not they have received the item being returned. (The ordering provider shall return the original product to the contractor with a written explanation of the problem and indicate the date they notified the contractor to remake the order.);

(A) Delivery Date: The contractor shall deliver the original order of materials and supplies to the ordering provider within seven business days of the date the order is received;

(B) Delay: In the event of a delay in manufacturing or delivery, the contractor shall:

(i) Notify the ordering provider within two (2) business days of receipt of the order;

(ii) Include a description of the order, the reason for delay and the revised time of completion and delivery; and

(C) Special Orders: Delivery of special-order frames and lenses may exceed the required delivery time. In this event, the contractor shall provide the ordering provider with notice of the anticipated delay, give the ordering provider a projected delivery date, and document the actual delivery time for future reference.

(4) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

(5) The contractor may use the date of order as the date of service (DOS) but may not bill the Division until the order has been completed and shipped.

(6) The contractor shall bill the Division using Health Care Common Procedure Coding System (HCPC) Codes listed in the contract agreement. Payment shall be at contracted rates.

(7) The contractor shall include eyeglass cases with every frame. Cases may not be included in orders for only lenses, temples or frame fronts.

(8) Frame Displays: Frames for display purposes may be purchased from the contractor for the same price as frames for glasses negotiated by the Oregon Department of Administrative Services:

(a) A case may not be provided with display frames; and

(b) Quantity, style, size and color of frames must be specified in the order for display frames.

(9) Contractors shall have unisex frame styles available and shall allow members to choose any frame regardless of category listed.

(10) Regardless of verification received via phone or electronic sources, the contractor may not fill orders for members who do not have coverage or have met their vision benefit. See OAR 410-140-0140 Vision Services Coverage and Limitations. When glasses are ordered and the member has met their vision benefit for the time period:

(a) The Division shall reimburse the provider for the exam only if the member is not an established member of the provider and the member is currently a fee-for-service (FFS) member with vision benefits.

(b) The provider needs to contact the member’s Managed Care Entity (MCE) if the member is enrolled with an MCE that contracts with SWEEP Optical. The contractor applies vision limitations included in rule, regardless of changes to a member’s enrollment status.

(11) Providers must:

(a) Verify the member’s eligibility and benefit coverage prior to submitting vision material orders to the contractor;

(b) Obtain PA from the Division for items requiring PA prior to placing a vision materials order;

(c) Comply with the contractor’s order submission requirements, as outlined in the Visual Services Supplemental Information Guide found at Division website: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;

(d) Submit prescription or order to the contractor upon notification of PA approval from the contractor; and

(e) Pay SWEEP Optical for any services, materials, and supplies provided by SWEEP Optical to a member who is not eligible for items. SWEEP Optical may not sell materials and supplies for non-eligible members at the State Contracted Price.

(12) The contractor shall:

(a) Forward Division PA approval to the provider;

(b) Order specifications:

(A) The contractor shall provide the order as specified by the ordering provider;

(B) The contractor shall pay for all shipping and handling charges for shipments to the provider via United States mail or United Parcel Service for all returned orders that do not meet the order specifications or that are damaged in shipping;

(C) The contractor may not accept initial orders via telephone. The contractor shall accept telephone calls or faxed messages regarding orders that do not meet specifications;

(D) When the contractor is notified of an item to be returned because the item was not made to specifications in the original order, the contractor shall begin remaking the product as soon as they are notified, whether or not they have received the item being returned. The ordering provider shall return the original product to the contractor with a written explanation of the problem and indicate the date they notified the contractor to remake the order;

(A) The contractor shall deliver the original order of materials and supplies to the provider within ten (10) business days of the date the order is received;

(B) In the event of a delay in manufacturing or delivery, the contractor shall:

(i) Notify the ordering provider within two (2) business days of receipt of the order;

(ii) Include a description of the order, the reason for delay, and the revised time of completion and delivery.

(C) Delivery of special-order frames and lenses may exceed the required delivery time. In this event, the contractor must provide the ordering provider with notice of the anticipated delay, provide a projected delivery date, and document the actual delivery time.

(13) The contractor:

(a) May use the date of order as the date of service (DOS) but may not bill the Division until the order has been completed and shipped;

(b) Shall bill the Division using Health Care Common Procedure Coding System (HCPC) Codes listed in the contract agreement. Payment shall be at contracted rates;

(c) Shall include eyeglass cases with every frame. Cases may not be included in orders for only lenses, temples, or frame fronts;

(d) Shall have unisex frame styles available and shall allow members to choose any frame regardless of category listed;

(e) Is not responsible if the Division determines the documentation in the member's record does not allow for the service pursuant to limitations indicated set forth in the administrative rules.

(14) The contractor and the Division may not pay for costs, expenses, or any required rework due to errors by the provider.

(15) The following services do not require PA, are subject to strict limitations, and require the physician or optometrist to submit appropriate documentation to contractor:

(a) Replacement parts for non-contracted frame styles are limited to frames purchased with PA approval;

(b) Tints and photochromic lenses are limited to members with documented albinism and pupillary defects. Documentation provided to contractor shall include the most appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code selected by a physician or optometrist;

(c) Other medically necessary items for a contract frame, when a member has a medical condition that requires the use of a specialty temple, nose pieces, head strap frame;

(d) Nonprescription glasses are limited to members who do not require any correction in one eye and where there is blindness in one eye. The purpose of this exception is to offer maximum protection for the remaining functional eye;

(e) High Index Lenses:

(A) Power is +/- 10 or greater in any meridian in either eye; or

(B) Prism diopters are 10 or more diopters in either lens;

(f) Polycarbonate lenses are limited to the following populations:

(A) Eligible children (birth through age 20);

(B) Members with developmental disabilities; and

(C) Members who are blind in one eye and need protection for the other eye, regardless of whether a vision correction is required.

(16) Regardless of verification received via phone or electronic sources, the contractor may not fill orders for members who do not have coverage or have met their vision benefit. When glasses are ordered and the member has met their vision benefit for the time period:

(a) The Division shall reimburse the provider for the exam only if the member is not an established member of the provider and the member is currently a FFS member with vision benefits;

(b) The provider shall contact the member’s PHP or CCO if the member is enrolled with a PHP or CCO that contracts with SWEEP Optical. The contractor shall apply vision limitations pursuant to Division rules, regardless of changes to a member’s enrollment status. The provider shall contact the member’s PHP or CCO with the last date of service. The PHP or CCO shall determine if they may allow for an additional supply of glasses. If the member is an established member, regardless of incomplete information through phone or electronic verification systems or SWEEP Optical, the provider shall inform the PHP or CCO of the last date of service.

(17) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 279A.140
DMAP 149-2024, minor correction filed 12/29/2024, effective 12/29/2024
DMAP 127-2024, amend filed 10/08/2024, effective 10/08/2024
DMAP 55-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 57-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 26-2014, f. 4-29-14, cert. ef. 5-8-14
DMAP 33-2011, f. 12-5-11, cert. ef. 12-6-11
DMAP 21-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 61-2005, f. 11-29-05, cert. ef. 12-1-05
OMAP 44-2001, f. 9-24-01, cert. ef. 10-1-01
HR 1-1996, f. 1-12-96, cert. ef. 1-15-96
HR 5-1995, f. & cert. ef. 3-1-95
HR 15-1994, f. & cert. e.f 3-1-94
HR 37-1992, f. & cert. ef. 12-18-92, Renumbered from 461-018-0300
AFS 75-1989, f. & cert. ef. 12-15-89

Or. Admin. R. 410-140-0410 Provider Responsibility

(1) The Oregon Health Authority (Authority) uses several approaches to promote program integrity and prevent fraud, waste and abuse in the Medicaid program (Refer to OAR 410-120-1395)

(2) The Division enrolls the following as providers of vision services:

(a) An individual licensed by the relevant state licensing authority to practice optometry; and

(b) A licensed ophthalmologist; and

(3) The provider must verify whether an MCE or the Division is responsible for reimbursement.

(a) Providers shall comply with MCE policies, including PA requirements, for reimbursement. Providers shall inform MCEs of the last date of service when inquiring about service limitations. Failure to follow MCE rules may result in the denial of payment; and

(b) If the provider has been denied payment for failure to follow the rules established by the MCE, neither the Division, the MCE, nor the MCE member are responsible for payment; and

(c) If the MCE uses the Division’s visual materials contractor or another visual materials contractor for visual materials and supplies, all issues shall be resolved between the MCE and the contractor; and

(d) Pursuant to OARs 410-120-1560 through 410-120-1700, the Provider may appeal a decision in which the provider is directly adversely affected.

(4) Providers shall comply with the following rules in addition to the Visual Services program rules to determine service coverage and limitations for OHP members according to their benefit packages:

(a) General Rules (OAR Chapter 410, Division 120);

(b) OHP administrative rules (Chapter 410, Division 141);

(d) Referenced guideline notes (The date of service determines the correct version of the administrative rules and HERC List to determine coverage.); and

(e) The Authority’s general rules related to provider enrollment and claiming (OAR 943-120-0300 through 1505).

(5) Providers must verify that an individual is an OHP member and eligible for benefits prior to providing services to ensure reimbursement for services provided. If the provider fails to confirm eligibility on the date of service, the provider may not be reimbursed. Providers must verify the member’s eligibility including:

(a) That the individual receiving vision services is eligible on the date of service for the service provided;

(b) Whether an OHP member receives services on a FFS basis or is enrolled with an MCE;

(d) Whether the service is covered by a third party resource (TPR).

(6) Providers must maintain accurate and complete member records, which includes documenting the quantity of services provided, as outlined in OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records). For comprehensive eye exams, the standard of care and expectation is that the provider shall provide a dilated exam and document the type of dilating drops and time of dilation.

(7) Providers must keep a copy of the delivery invoice included with all parts orders in the member's records or document the delivery invoice number in the member's records for all repair and refitting claims.

(8) The provider shall inform an OHP member when:

(a) Vision service or materials are not covered under the members benefit package;

(b) Service limitations have been met and the benefit is no longer covered.

(9) Providers must:

(a) Verify the member’s eligibility and benefit coverage prior to submitting vision material orders to the contractor;

(b) Obtain PA from the Division for items requiring PA prior to placing a vision materials order;

(d) Submit prescription or order to the contractor upon notification of PA approval from the contractor; and

(10) Post-operative care provided outside the global package is:

(a) Reimbursable to optometrists when furnished within their scope of practice;

(b) Billed with:

(A) The surgical CPT code billed by the surgeon;

(B) The appropriate modifier noting post-operative care only; and

(11) Providers are responsible for:

(a) Verifying member eligibility prior to submitting an order to the contractor. Refer to OAR 410-120-1140 Verification of Eligibility;

(b) Obtaining prior authorization (PA) from the Division for items requiring PA prior to placing a vision materials order. (See OAR 410-140-0040 Prior Authorization.);

(c) Complying with the contractor’s order submission requirements, as outlined in the Visual Services Supplemental Information Guide found on this Division website: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;

(d) Submitting prescription/order to the contractor upon notification of PA approval from the contractor; and

(e) Paying SWEEP Optical for any services provided by SWEEP Optical to a member who is not eligible for items. SWEEP Optical is prohibited by contract to sell materials and supplies for non-eligible members at the State Contracted Price.

(12) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

(13) It is the provider’s responsibility to contact the member’s PHP of CCO and give them the last date of service. The current PHP or CCO shall then determine if they want to allow for an additional supply of glasses. If the member is an established member, regardless of incomplete information through phone or electronic verification systems or SWEEP Optical, it is the provider’s responsibility to inform the PHP/CCO of the last date of service.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.025, 414.065, 414.591 & 414.631
DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024

Or. Admin. R. 410-140-0415 Codes

(1) Providers shall use an International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnosis code on all claims.

(2) Providers shall provide the member's diagnosis to ancillary service providers (e.g., SWEEP Optical Laboratories) when prescribing services, equipment, and supplies.

(3) Providers shall use the standardized code sets required by the Health Insurance Portability and Accountability Act (HIPAA) and adopted by the Centers for Medicare and Medicaid Services (CMS). Providers shall accurately code claims using the combination of Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes in effect for the date the service was provided:

(a) Providers may not bill CPT or HCPCS procedure codes for separate procedures when a single CPT or HCPCS code includes all services provided. Providers shall comply with published coding guidelines;

(b) Intermediate and comprehensive ophthalmological services as described under the ophthalmology section of the CPT codebook shall be billed using codes included under this section and not those included under the Evaluation and Management section;

(c) When there is no appropriate descriptive procedure code to bill the Division, the provider shall use the code for “unlisted services.”

(4) The Division recognizes HIPAA compliant modifiers in coding.

(5) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.025, 414.065, 414.591 & 414.631
DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024

Or. Admin. R. 410-140-0420 Prior Authorizations

(1) If a member has FFS the Division may require a Prior Authorization (PA) for certain covered services or items before the service may be provided and before payment is made; and

(2) Prior Authorization (PA) is defined in OAR 410-120-0000, OAR 410-120-1320, and OAR 410-140-0420. Providers must obtain a PA from the:

(a) Enrolled member’s Managed Care Entity (MCE); or

(b) The Division for members who receive services on a fee-for-services basis and are not enrolled with an MCE.

(3) A PA does not guarantee eligibility or reimbursement. Providers must verify the member’s eligibility on the date of service whether an MCE, or the Division is responsible for reimbursement.

(4) A PA is not required for members with Medicare or TPL and Division coverage when the service or item is covered by Medicare or TPL.

(5) Providers shall determine if a PA is required and comply with all PA requirements outlined in these rules.

(6) Providers shall ensure:

(a) That all PA requests are completed and submitted correctly. The Division does not accept PA requests via the phone. See Visual Services Supplemental Information Guide found at www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;

(b) PA requests must include:

(A) A statement of medical appropriateness and medical necessity showing the need for the item or service and why other options are inappropriate;

(B) Diopter information and appropriate International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnosis codes;

(C) All relevant documentation that is needed for Division staff to make a determination for authorization of payment, including clinical data or evidence, medical history, any plan of treatment, or progress notes;

(c) The service is adequately documented. (See OAR 410-120-1360 Requirements for Financial, Clinical and Other Records.) Providers must maintain documentation to adequately determine the type, medical appropriateness, or quantity of services provided;

(d) The services or items provided are consistent with the information submitted when PA was requested;

(e) The services billed are consistent with the services provided; and

(f) The services are provided within the timeframe specified on the PA document.

(7) Providers shall comply with the Division’s PA requirements or other policies necessary for reimbursement before providing services to any OHP member who is not enrolled in an MCE. Services or items denied due to provider error (e.g., required documentation not submitted, PA not obtained, etc.) may not be billed to the member.

(8) The following vision services require PA:

(a) Contact lenses for adults (age 21 and older) and excludes a primary keratoconus diagnosis, which is exempt from the PA requirement. (See OAR 410-140-0160 Contact Lens Services for service and supply coverage and limitations);

(b) Vision therapy greater than six (6) sessions. Six (6) sessions are allowed per calendar year without PA. (See OAR 410-140-0280 Vision Therapy Services); and

(A) Frames not included in the Division’s contract with contractor, SWEEP Optical; and

(B) Specialty lenses or lenses considered as “not otherwise classified” by Health Care Common Procedure Coding System (HCPCS);

(d) Any unlisted ophthalmological service or procedure, or “By Report” (BR) procedures.

(9) The Division shall send notice of all approved PA requests for vision materials to the Division’s contractor, SWEEP Optical; who forwards a copy of the PA approval and confirmation number to the requesting provider. (Refer to OAR 410-140-0200)

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 343.146, 414.065, 683.010 -683.340 & 743A.250
DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024

Or. Admin. R. 410-140-0425 Meaningful Language Access

(1) Providers shall take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in program services at all visual service care visits:

(a) The size or type of provider does not matter. All providers serving OHP members shall tell members that qualified health interpreter services are available free of charge. Interpreter services shall be timely and protect the privacy and independence of the person with LEP;

(b) Bilingual providers and staff may become Certified Health Care Interpreters after completing the requisite interpreter training and receiving a valid certificate from the Authority;

(c) The Authority’s Health Care Interpreter Registry lists all qualified or certified Health Care Interpreters available for provider use;

(d) Fee-for-Service (FFS) vision providers may receive a $60 add-on fee, per date of service, for providing interpreter services to OHP members. The addition of this add-on fee for FFS visits does not change CCO requirements related to reimbursement of qualified and certified HCIs for interpretation services.

(2) FFS vision providers who furnish Certified Health Care Interpreter (HCI) services to OHP members are eligible to receive a $60 add-on fee per date of service. The Authority shall cover this fee only when:

(a) The fee is billed in conjunction with a covered OHP service or medically necessary follow-up visit related to the initial Covered Service;

(b) The fee is not billed in conjunction with bundled rate services that incorporate administrative costs (e.g., inpatient hospital stays, home health or hospice visits, services provided by long-term care facilities, or services billed at an encounter rate by rural health clinics, federally qualified health centers and tribal health centers); and

(c) The language assistance service is provided by a qualified or Certified Health Care Interpreter as described in Oregon Revised Statute (ORS) Chapter 413.

(3) Billing: Providers shall verify that the interpreter is registered with the Authority’s Health Care Interpreter Registry. If the interpreter is registered, providers pay the interpreter directly for services provided. After payment is made to the interpreter, bill the Authority for the add-on fee on the claim form:

(a) Add the appropriate code to a new line on the claim form;

(b) Keep Documentation in the member’s medical record that indicates use of the qualified or certified Health Care Interpreter for any potential audit of services billed.

History

Statutory/Other Authority: ORS 414.572 & 413.550
Statutes/Other Implemented: ORS 414.572 & 413.550
DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024

Or. Admin. R. 410-140-0430 Limitations and Exclusions

(1) Buying up, as defined in OAR 410-120-1350 is prohibited.

(2) Vision therapy is not covered except under EPSDT when medically necessary and medically appropriate (Refer to Chapter 410, Division 151).

(3) The following ophthalmic materials are not covered and include, but are not limited to:

(a) Glasses with a prescription that is equal to or less than +/-.25 diopters in both eyes;

(b) Two (2) pair of glasses instead of bifocals or trifocals in a single frame;

(d) Non-spectacle mounted aids;

(e) Single lens spectacle mounted low vision aids;

(f) Telescopic and other compound lens systems, including distance vision telescopic, near vision telescopes, and compound microscopic lens systems;

(g) Extra or spare pairs of glasses;

(h) Anti-reflective lens coating;

(i) U-V lens;

(j) Progressive and blended lenses;

(k) Bifocals and trifocals segments over 28mm including executive;

(L) Aniseikonic lenses;

(m) Sunglasses; and

(n) Frame styles outside of the contract between the Division and contractor based on member preference and are not medically necessary.

(4) Post-operative care includes all related follow-up visits and examinations provided within:

(a) Ninety (90) days following the date of major surgery; or

(b) Ten (10) days following the date of minor surgery; and

(c) Claims for evaluation and management services and ophthalmological examinations billed within the follow-up period shall be denied.

(5) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.025, 414.065, 414.591 & 414.631
DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024

Division 141 OREGON HEALTH PLAN

Or. Admin. R. 410-141-3500 Definitions

(1) The following definitions apply with respect to OAR chapter 410, division 141. The Oregon Health Authority (Authority) also incorporates the definitions in OAR 410-120-0000, 309-032-0860 for any terms not defined in this rule.

(2) “Adjudication” means the act of a court or entity in authority when issuing an order, judgment, or decree, as in a final Managed Care Entity (MCE) claims decision or the Authority issuing a final hearings decision. For a final Managed Care Entity (MCE) claims decision, the date of “Adjudication” is the date on which an MCE has both (a) processed and (b) either paid or denied a Member’s claim for services.

(3) “Aging and People with Disabilities (APD)” means the division in the Oregon Department of Human Services (ODHS) that administers programs for seniors and people with disabilities, as set forth in OAR 410-120-0000.

(4) “Area Agency on Aging (AAA)” means the designated entity with which the ODHS contracts in planning and providing services to elderly populations, as set forth in OAR 410-120-0000.

(5) “The Authority” means the Oregon Health Authority (OHA).

(6) “Alternate Format” means any alternate approach to presenting print information to an individual with a disability. The Americans with Disabilities Act (ADA) groups the standard alternate formats: braille, large (18 point) print, audio narration, oral presentation, and electronic file along with other aids and services for other disabilities, including sign language interpretation and sighted guide; Centers for Medicare and Medicaid Services (CMS) Section 1557 of the Affordable Care Act (ACA) outlines requirements for health plans and providers on alternative formats.

(7) “Auxiliary Aids and Services” means services available to members as defined in 45 Code of Federal Regulations (CFR) Part 92.

(8) “Behavioral Health” means mental health, mental illness, addiction disorders, and substance use disorders.

(9) “Benefit Period” means a period of time shorter than the five-year contract term, for which specific terms and conditions in a contract between a coordinated care organization and the Authority are in effect.

(10) “Business Day” means any day except Saturday, Sunday, or a legal holiday recognized by the State of Oregon. The word "day" not qualified as business day means calendar day.

(11) “Capitated Services” means those covered services that a Managed Care Entity (MCE) agrees to provide for a capitation payment under contract with the Authority.

(12) “Capitation Payment” means monthly prepayment to a Managed Care Entity (MCE) for capitated services to Managed Care Entity (MCE) members.

(13) “Care Coordination” means the act and responsibility of CCOs to deliberately organize a Member’s overall benefits, services, care activities (e.g., assessments, case management, care planning) and information sharing among a member’s care team, according to the physical, developmental, behavioral, oral and social needs (including Health Related Social Needs and Social Determinants of Health and Equity) of the Member. Care Coordination requirements are described in OAR 410-141-3860, 410-141-3865, 410-141-3870, and in accordance with 42 CFR 438.208.

(14) "Care Plan" means a document (digital or paper) that is developed for and in collaboration with the Member, their family, representatives or guardian, to the extent they desire or are able to participate, and in consultation with the Member’s providers, community supports and services, where applicable, to ensure continuity and coordination of a Member’s care according to their needs. Care Plan requirements are described in OAR 410-141-3865 and 410-141-3870.

(15) “Care Profile” means the electronic health record a CCO develops and maintains for all members. The Care Profile is the platform that receives feeds from different data sources used to identify, track and manage a Member’s needs and risk level to direct the frequency of the CCOs outreach and Care Coordination activities/opportunities that shall be offered to the Member including, but not limited to, care management and appropriate Care Plans. Care Profile requirements are further described in OAR 410-141-3865 and OAR 410-141-3870.

(16) “Care Setting Transitions” means a transition between different locations, settings or levels of care.

(17) “Certificate of Authority” means the certificate issued by Department of Consumer and Business Services (DCBS) to a licensed health entity granting authority to transact insurance as a health insurance company or health care service contractor.

(18) “Client” means an individual found eligible to receive Oregon Health Plan (OHP) health services, whether or not the individual is enrolled as an CCO member.

(19) “Community Advisory Council (CAC)” means the CCO-convened council that meets regularly to ensure the CCO is addressing the health care needs of CCO members and the community consistent with ORS 414.572 and in accordance with criteria specified in ORS 414.575. CCOs shall seek an opportunity for tribal participation on CACs to bring nominee(s) to the attention of the CAC Selection Committee as follows:

(a) In a Service Area where only one (1) federally recognized tribe exists, the CCO shall seek one (1) tribal representative to serve on the CAC;

(b) In Service Areas where multiple federally recognized tribes exist, the CCO shall seek one (1) tribal representative from each tribe to serve on the CAC; and

(c) In metropolitan Service Areas where no federally recognized tribe exists, CCOs shall solicit the Urban Indian Health Program for a representative to serve on the CAC.

(20) “Community Benefit Initiatives” (CBI) means community-level interventions focused on improving population health and health care quality.

(21) “Condition-Specific Program” and “Condition-Specific Facility” mean programs or facilities that treat a narrowly defined illness, disorder or condition, such as:

(a) Behavioral and Mental Health conditions, Substance Use Disorder (SUD) or addiction, including but not limited to;

(A) Alcohol;

(B) Illicit Drugs; and

(b) Physical Health conditions, including but not limited to:

(A) Cancer;

(B) Diabetes;

(22) “Continuous Inpatient Stay" means an uninterrupted period of time that a patient spends as inpatient, regardless of whether there have been changes in assigned specialty or facility during the stay. This includes discharge transfer to another inpatient facility, in or out of state, such as another acute care hospital, acute care psychiatric hospital, skilled nursing facility, psychiatric residential treatment facility (PRTF) or other residential facility for inpatient care and services.

(23) “Contract” means an agreement between the State of Oregon acting by and through The Authority and a Managed Care Entity (MCE) to provide health services to eligible members.

(24) “Coordinated Care Organization (CCO)” means a corporation, governmental agency, public corporation, or other legal entity that is certified as meeting the criteria adopted by the Authority under ORS 414.572 to be accountable for care management and to provide integrated and coordinated health care for each of the organization’s members.

(25) “Coordinated Care Organization Payment or CCO Payment” means the monthly payment to a Coordinated Care Organization (CCO) for services the CCO provides to members in accordance with the global budget.

(26) “Coordinated Care Services” means a Managed Care Entity’s (MCE) fully integrated physical, developmental, behavioral, oral and social needs (including Health Related Social Needs and Social Determinants of Health and Equity) services.

(27) “Corrective Action” or “Corrective Action Plan (CAP)” means an Authority-initiated request for a Managed Care Entity (MCE) or a Managed Care Entity (MCE)-initiated request for a subcontractor to develop and implement a time specific plan for the correction of identified areas of noncompliance.

(28) “Culturally and Linguistically Responsive and Appropriate Services” means the provision of effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural beliefs and practices, preferred languages, health literacy, and other communication needs. Culturally and Linguistically appropriate services are further defined in 42 CFR § 59.2.

(29) “Delivery System Network (DSN)” means the entirety of those Participating Providers who:

(a) Contracts with; or

(b) Are employed by, a CCO for purposes of providing services to the Members of such CCO. “Provider Network” has the same meaning.

(30) “Dental Subcontractor” has the meaning as provided for in 410-120-0000.

(31) “Department” means the Oregon Department of Human Services (ODHS).

(32) “Department of Consumer and Business Services (DCBS)” means Oregon’s business regulatory and consumer protection department.

(33) “Disenrollment” means the act of removing a member from enrollment with an MCE.

(34) "Diversity of the workforce" refers to the ethnic, racial, linguistic, gender, and social variation among members of the health professional workforce. It is generally understood that a more diverse workforce represents a greater opportunity for better quality health care service, due to the array of life experiences and empathy of a mix of providers that can be brought to the delivery of health care.

(35) “Downstream Entity” means any party that enters into a written contract or other agreement with a CCO’s subcontractor pursuant to which such party performs one or more of the obligations of the Subcontractor under the subcontractor’s subcontract with the CCO. Regardless of the number of parties that are downstream from a CCO’s subcontractor, a party is deemed a “downstream entity” of a CCO subcontractor if such party is, pursuant to a written or oral contract or agreement, performing the obligations the subcontractor is required to perform on behalf of the CCO under its subcontract therewith.

(36) “Encounter Data” means the information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between a State and a Managed Care Entity (MCE) that is subject to the requirements of 42 CFR 438.242 and 42 CFR 438.818 and under OAR 410-141-3570 and related to services that were provided to Members regardless of whether the services provided:

(a) Were covered services, non-covered services, or other Health-Related Social Needs services; or

(b) Were not paid; or

(d) Were performed by a Participating Provider, Non-Participating Provider, Subcontractor, or Contractor; and

(e) Were performed pursuant to Subcontractor agreement, special arrangement with a facility or program, or other arrangement.

(37) “Enrollment” means the assignment of a member to a Managed Care Entity (MCE) for management and coordination of health services.

(38) “Family Planning” means services that enable individuals to plan and space the number of their children and avoid unintended pregnancies. The Oregon Health Plan covers family planning services for clients of childbearing age, including minors who are considered to be sexually active. Family Planning services include:

(a) Annual exams;

(b) Contraceptive education and counseling to address reproductive health issues;

(d) IUDs and implantable contraceptives and the procedures requires to inserted remove them;

(e) Injectable hormonal contraceptives (such as Depo-Provera);

(f) Prescribed pharmaceutical supplies and devices (such as male and female condoms, diaphragms, cervical caps, and foams);

(g) Laboratory tests including appropriate infectious disease and cancer screening;

(h) Radiology services;

(i) Medical and surgical procedures, including vasectomies, tubal ligations and abortions.

(39) “Flexible Services” means non-covered services under Oregon’s Medicaid State Plan intended to improve care delivery and overall member and community health and well-being, as defined in OAR 410-141-3845.

(40) “Global Budget” means the total amount of payment as established by the Authority to a CCO to deliver and manage health services for its members including providing access to and ensuring the quality of those services.

(41) “Grievance System” means the overall system that includes:

(a) Grievances to a Managed Care Entity (MCE) on matters other than adverse benefit determinations;

(b) Appeals to a Managed Care Entity (MCE) on adverse benefit terminations; and

(c) Contested case hearings through the Authority on adverse benefit determinations and other matters for which the member is given the right to a hearing by rule or statute.

(42) “Health Literacy” means the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions regarding services needed to prevent or treat illness.

(43) “Health Risk Assessment (HRA)” means a survey or questionnaire administered verbally, digitally or in writing, to collect information from a Member, their representative or guardian about key areas of the Member’s health, including their physical, developmental, behavioral, oral and social needs (including Health Related Social Needs and Social Determinants of Health and Equity). The HRA is intended to inform the coordination of services and supports that meet the Members individualized needs as described in OAR 410-141-3860, 410-141-3865 and 410-141-3870.

(44) “Health System Transformation” means the vision established by the Oregon Health Policy Board for reforming health care in Oregon, including both the Oregon Integrated and Coordinated Health Care Delivery System and reforms that extend beyond the context of Oregon Health Plan (OHP).

(45) “Home CCO” means the CCO enrollment situation that existed for a member prior to placement, including services received through Oregon Health Plan (OHP) fee-for-service, based on permanent residency.

(46) “Indian” and/or “American Indian/Alaska Native (AI/AN)” means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, under 42 CFR 136.12; or as defined under 42 CFR 438.14(a).

(47) “Indian Health Care Provider (IHCP)” means a health care program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise known as an I/T/U) as those terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. § 1603).

(48) “In Lieu of Service” (ILOS) means a setting or service determined by the Authority to be a medically appropriate and cost-effective substitute for a Covered Services consistent with provisions in OAR 410-141-3820. The utilization and actual cost of an ILOS is included in developing the components of the Capitation Payment. In lieu of services must meet the requirements of 42 CFR 438.3(e)(2).

(49) “Individual with Limited English Proficiency” means a person whose primary language for communication is not English and who has a limited ability to read, write, speak, or understand English.

(50) “Institution for Mental Diseases (IMD)” means, as defined in 42 CFR § 435.1010, a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing inpatient psychiatric services such as diagnosis, treatment, or care of individuals with mental diseases, including medical attention, nursing care, and related services. Its primary character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

(51) “Legal Holiday” means the days described in ORS 187.010 and 187.020.

(52) “Licensed Health Entity” means a Managed Care Entity (MCE) that has a Certificate of Authority issued by DCBS as a health insurance company or health care service contractor.

(53) “Local Mental Health Authority” means one of the following entities:

(a) The board of county commissioners of one or more counties that establishes or operates a community mental health program;

(b) The tribal council, in the case of a federally recognized tribe of Native Americans that elects to enter into an agreement to provide mental health services; or

(54) “Local Planning Committee” means a local planning committee for alcohol and drug prevention and treatment services appointed or designated by the county governing body under ORS 430.342.

(55) “Managed Care Entity (MCE)” is a general term that means an entity that enters into one or more contracts with the Authority to provide services in a managed care delivery system, including but not limited to the following types of entities defined in and subject to 42 CFR Part 438: managed care organizations (MCOs), primary care case managers (PCCMs), prepaid ambulatory health plans (PAHPs), and prepaid inpatient health plans (PIHPs). A CCO is an MCE for its managed care contract(s) with the Authority, without regard to whether the contract(s) involves federal funds or state funds or both.

(56) “Managed Care Organization (MCO)” is a specific term that means an MCE defined in 42 CFR Part 438. A CCO is an MCO for its managed care contract(s) subject to federal managed care requirements specified in 42 CFR Part 438.

(57) “Material Change to Delivery System” means:

(a) Any change to the CCO’s Delivery System Network (DSN) that may result in more than five (5) percent of either its total Members or its Members in a county changing the physical location(s) of where services are received; or

(b) Any change to CCO’s DSN that may likely affect less than five (5) percent of its Members but involves a Provider or Provider group that is the sole provider specialty type within the overall Provider Network or is the sole provider specialty type with a practice within a county in the CCO’s service area; or

(c) Any change in CCO’s overall operations that affects its ability to meet a required DSN standard including, but not limited to: termination or loss of a Provider or Provider group, or any change likely to affect more than five (5) percent of CCO’s total Members or Provider Network or both; or

(d) Any combination of the above changes.

(58) “Medicaid-Funded Long-Term Services and Supports (LTSS)” means all Medicaid funded services CMS defines as long-term services and supports, including both:

(a) “Long-term Care,” the system through which the Department of Human Services provides a broad range of social and health services to eligible adults who are aged, blind, or have disabilities for extended periods of time. This includes nursing homes and behavioral health care outlined in OAR chapter 410, division 172 Medicaid Payment for Behavioral Health Services, including state psychiatric hospitals;

(b) “Home and Community-Based Services,” the Medicaid services and supports provided under a CMS-approved waiver to avoid institutionalization as defined in OAR chapter 411, division 4 and defined as Home and Community-Based Services (HCBS) and as outlined in OAR chapter 410, division 172 Medicaid Payment for Behavioral Health Services.

(59) “Member” has the meaning provided for in OAR 410-120-0000.

(60) “Member Representative” means an individual who can make Oregon Health Plan (OHP)-related decisions for a member who is not able to make such decisions themselves.

(61) “National Association of Insurance Commissioners (NAIC)” means the U.S. standard-setting and regulatory support organization created and governed by the chief insurance regulators from the 50 states, the District of Columbia, and five U.S. territories.

(62) “Non-Participating Provider” means a provider that does not have a contractual relationship with an MCE and is not on their panel of providers.

(63) “Ombudsperson Services” means patient advocacy services available through the Authority for clients who are concerned about access to, quality of, or limitations in the health services provided.

(64) “Oral Health” has the meaning provided for in OAR 410-123-1060.

(65) “Oregon Health Plan (OHP)” means Oregon’s Medicaid program or related state-funded health programs. Any OHP contract shall identify whether it concerns Oregon’s Medicaid program or a related state-funded health program, or both.

(66) “Oregon Integrated and Coordinated Health Care Delivery System” means the set of state policies and actions that promote integrated care delivery by CCOs to OHP clients, pursuant to ORS 414.570.

(67) “Participating Provider” means a provider that has a contractual relationship with an MCE. A Participating Provider is not a Subcontractor solely by virtue of a Participating Provider agreement with an MCE. “Network Provider” has the same meaning as Participating Provider.

(68) “Patient-Centered Primary Care Home (PCPCH)” means a recognized clinic that takes a patient and family-centered approach to all aspects of care. PCPCHs work with the member and their health care team to improve and coordinate care and help to eliminate repetitive procedures. As defined in ORS 414.655, meets the standards pursuant to OAR 409-055-0040, and has been recognized through the process pursuant to OAR 409-055-0040 and means the definition as set forth in OAR 409-055-0010.

(69) “Permanent Residency” means the county code-zip code combination of the physical residence in which the member/client lived, as found in the benefit source system, prior to placement and to which the member/client is expected to return to after placement ends.

(70) “Plan Type” means the designation used by the Authority to identify which health care services covered by a client’s OHP Plus or equivalent benefit package are paid by a CCO, by the Authority’s fee-for-service program, or both. If a client does not have a plan type designation, then all of the client’s health care services are paid by the fee-for-service program. Regardless of plan type, some health care services are carved out from CCOs by contract or rule and are instead paid by the fee-for-service program. The plan type designations are as follows:

(a) CCOA: Physical, dental, and behavioral health services are paid by the client’s CCO;

(b) CCOB: Physical and behavioral health services are paid by the client’s CCO. Dental services are paid the fee-for-service program;

(c) CCOE: Behavioral health services are paid by the client’s CCO. Physical health and dental services are paid by the fee-for-service program;

(d) CCOF: Dental services are paid by the client’s CCO. Physical health and behavioral health services are paid by the fee-for-service program, except for individuals receiving dental services through the Compact of Free Association (COFA) Dental Program or the Veteran Dental Program defined in OAR chapter 410, division 120. Any reference to CCOF means the benefit package covers dental services only; and

(e) CCOG: Dental and behavioral health services are paid by the client’s CCO. Physical health services are paid by the fee-for-service program.

(71) “Post Hospital Extended Care Services” (PHECS). Consistent with 42 USC § 1395x(i), PHECS means extended care services furnished an individual after transfer from a hospital in which a member was an inpatient for not less than three (3) consecutive days before discharge from the hospital in connection with such transfer. For purposes of the preceding sentence, items and services shall be deemed to have been furnished to a member after transfer from a hospital, and the member shall be deemed to have been an inpatient in the hospital immediately before transfer there from, if the member is admitted to the skilled nursing facility:

(a) Within thirty (30) days after discharge from such hospital; or

(b) Within such time as it may be medically appropriate to begin an active course of treatment, in the case of an individual whose condition is such that skilled nursing facility care may not be medically appropriate within thirty (30) days after discharge from a hospital; and

(c) An individual shall be deemed not to have been discharged from a skilled nursing facility if, within thirty (30) days after discharge therefrom, the member is admitted to such facility or any other skilled nursing facility.

(72) “Potential Member” means an individual who meets the eligibility requirements to enroll in the Oregon Health Plan but has not yet enrolled with a specific MCE.

(73) “Primary Care Provider (PCP)” means an enrolled medical assistance provider who has responsibility for supervising, coordinating, and providing initial and primary care within their scope of practice for identified clients. PCPs are health professionals who initiate referrals for care outside their scope of practice, consultations, and specialist care, and assure the continuity of medically appropriate client care. PCPs include:

(a) The following provider types: physician, naturopath, nurse practitioner, physician associate or other health professional licensed or certified in this state, whose clinical practice is in the area of primary care;

(b) A health care team or clinic certified by the Authority as a PCPCH as defined in OAR 409-055-0010 and OAR 410-120-0000.

(74) “Provider” means an individual, facility, institution, corporate entity, or other organization that:

(a) Is engaged in the delivery of services or items or ordering or referring for those services or items; or

(b) Bills, obligates, and receives reimbursement from the Authority’s Health Services Division on behalf of a Provider, (and also termed a “Billing Provider”); and

(75) “Readily Accessible” means electronic information and services that comply with the World Wide Web Consortium (W3C) Web Content Accessibility Guidelines (WCAG) 2.2 Levels A and AA, and successor versions. This fulfills digital accessibility requirements under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) Title II.

(76) "Risk" in the context of Care Coordination is the combination of a Member's health needs based on their physical, development, behavioral, oral, and social health status (including Health Related Social Needs and Social Determinants of Health and Equity) that creates an increased chance of having a negative health outcome that could be prevented by effective Care Coordination that addresses those needs.

(77) "Rising Risk" means health related circumstance changes or events a Member may experience as described in OAR 410-141-3865, that are likely to increase risk level or negatively impact their physical, developmental, behavioral, oral or social needs (including Health Related Social Needs and Social Determinants of Health and Equity) or wellbeing from a previously identified or existing level of risk.

(78) "Risk Stratification" means the process by which CCOs employ continuous data feeds, analysis, application of appropriate clinical or practical subjectivity and other factors to score a members identified physical, behavioral, developmental, oral and social needs (including Health Related Social Needs and Social Determinants of Health and Equity) and assign an appropriate risk level. Risk Stratification informs the level at which the CCOs coordinated services and activities (e.g., assessments, appropriate care planning, referrals) are deployed to meet the Member's needs.

(79) “Service Area” means the geographic area within which the MCE agreed under contract with the Authority to provide health services.

(80) “Serious Emotional Disorder” (SED) means a subpopulation of individuals under age 21 who meet the following criteria:

(a) An infant, child or youth, between the ages of birth to 21 years of age; and

(b) Must meet criteria for diagnosis, functional impairment and duration:

(A) Diagnosis: The infant, child or youth must have an emotional, socio-emotional, behavioral or mental disorder diagnosable under the DSM-5 or its ICD-10-CM equivalents, or subsequent revisions (with the exception of DSM “V” codes, substance use disorders and developmental disorders, unless they co-occur with another diagnosable serious emotional, behavioral, or mental disorder):

(i) For children three (3) years of age or younger. The child or youth must have an emotional, socio-emotional, behavioral or mental disorder diagnosable under the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC: 0-3R) (or subsequent revisions);

(ii) For children four (4) years of age and older. The child or youth must have an emotional, socio-emotional, behavioral or mental disorder diagnosable under the Diagnostic Interview Schedule for Children (DISC) or DSM-5 or its ICD-10-CM equivalents, or subsequent revisions (with the exception of DSM “V” codes, substance use disorders and developmental disorders, unless they co-occur with another diagnosable serious emotional, behavioral, or mental disorder).

(B) Functional impairment: An individual is unable to function in the family, school or community, or in a combination of these settings; or the level of functioning is such that the individual requires multi-agency intervention involving two or more community service agencies providing services in the areas of mental health, education, child welfare, juvenile justice, substance abuse, or primary health care;

(C) Duration: The identified disorder and functional impairment must have been present for at least one (1) year or, on the basis of diagnosis, severity or multi-agency intervention, is expected to last more than one (1) year.

(81) Social Determinants of Health and Equity (SDOH-E) has the meaning provided for in OAR 410-141-3735.

(82) “Special Health Care Needs” has the meaning provided for in OAR 410-120-0000.

(83) “Subcontract” means either:

(a) A contract between a CCO and a subcontractor pursuant to which such subcontractor is obligated to perform certain work that is otherwise required to be performed by the CCO under its contract with the State; or

(b) Is the infinitive form of the verb “to Subcontract”, i.e. the act of delegating or otherwise assigning to a Subcontractor certain work required to be performed by an MCE under its contract with the State.

(84) "Subcontractor" means an individual or entity that has a contract with an MCE that relates directly or indirectly to the performance of the MCE's obligations under its contract with the State. A Participating Provider is not a Subcontractor solely by virtue of having entered into a Participating Provider agreement with an MCE.

(85) “Transition of Care” applies to Medicaid members who are enrolled in a CCO (“the receiving CCO”) immediately after disenrollment from a “predecessor plan” which may be another CCO (including disenrollment resulting from termination of the predecessor CCO’s contract) or Medicaid fee-for-service (FFS). Transition of Care does not apply to a member who is ineligible for Medicaid or who has a gap in coverage following disenrollment from the predecessor plan. Meets the standards pursuant to OAR 410-141-3850.”

(86) “Trauma Informed Approach” means approach undertaken by providers and healthcare or human services programs, organizations, or systems in providing mental health and substance use disorders treatment wherein there is a recognition and understanding of the signs and symptoms of trauma in, and the intensity of such trauma on, individuals, families, and others involved within a program, organization, or system and then takes into account those signs, symptoms, and their intensity and fully integrating that knowledge when implementing and providing potential paths for recovery from mental health or substance use disorders. The Trauma Informed Approach also means that providers and healthcare or human services programs, organizations, or systems and actively resist re-traumatization of the individuals being served within their respective entities.

(87) “Temporary Placement” means, for purposes of this rule, hospital, institutional, and residential placement only, including those placements occurring inside or outside of the service area with the expectation to return to the Home CCO service area.

(88) "Trauma-informed services" means those services provided using a Trauma Informed Approach.

(89) “Treatment Plan” means a documented plan that describes the patient's condition and procedures that shall be needed, detailing the treatment to be provided and expected outcome and expected duration of the treatment prescribed by the health care professional. This therapeutic strategy shall be designed in collaboration with the member, the member’s family, or the member’s representative.

(90) “Urban Indian Health Program” (UIHP) means an urban Indian organization as defined in section 1603 of Title 25 that has an IHS Title V contract as described in section 1653 of Title 25.

(91) "Workforce diversity capacity" means the organization's ability to foster an environment where diversity is commonplace and enhances execution of the organization's objectives. It means creating a workplace where differences demographics and culture are valued, respected and used to increase organizational capacity.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 74-2025, amend filed 09/26/2025, effective 09/29/2025
DMAP 50-2025, amend filed 06/20/2025, effective 06/20/2025
DMAP 26-2025, minor correction filed 01/22/2025, effective 01/22/2025
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 140-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 81-2024, minor correction filed 04/01/2024, effective 04/01/2024
DMAP 37-2024, amend filed 01/25/2024, effective 02/01/2024
DMAP 8-2023, minor correction filed 03/01/2023, effective 03/01/2023
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3501 Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation; Rule Precedence

(1) The Authority may adopt reasonable and lawful policies, procedures, rules and interpretations to promote the orderly and efficient administration of the Oregon Integrated and Coordinated Health Care Delivery System and medical assistance programs. This includes the Oregon Health Plan (OHP) pursuant to ORS Chapter 414, subject to the rulemaking requirements of Oregon Revised Statutes and Oregon Administrative Rule (OAR) procedures.

(2) To the extent possible, the Authority’s policies, procedures, rules, and MCE contracts shall be interpreted to avoid a conflict among themselves or with governing state or federal law. In the event of an irreconcilable conflict, the following order of precedence shall govern:

(a) Medicaid Plan and waivers or other directives from CMS;

(b) Federal Statutes;

(d) Oregon Revised Statutes;

(e) Oregon Administrative Rules using the following order of precedence:

(A) This OAR chapter 410 division 141 (“Oregon Health Plan”);

(B) OAR chapter 410 division 120 (“Medical Assistance Programs”);

(D) OAR Chapter 943, Division 120;

(E) OAR Chapter 309;

(F) All other applicable OARs;

(f) The MCE Contract, including any internal order of precedence established therein.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3505 Use of Subcontractors

(1) MCEs may delegate their activities or obligations to subcontractors except as otherwise provided by law or in the MCE contract:

(a) MCEs remain fully accountable for the performance of all subcontracted work, including that of all downstream entities contracted by MCE’s subcontractor;

(b) MCEs shall monitor subcontractor performance on an ongoing basis;

(A) A comprehensive list of subcontractor and downstream entities and, for each one, the activities and functions that have been delegated, to be submitted to OHA on an annual basis;

(B) Copies of all subcontracts upon request; and

(C) Adequate documentation demonstrating monitoring of subcontractor compliance or subcontractor auditing, as applicable, in accordance with the contract and with CMS requirements including 42 C.F.R §§ 438.230, 438.602(a) and 438.66.

(2) Each subcontract must include the following elements:

(a) With respect to any MCE activities or obligations defined by law or in the MCE’s contract with the Authority that the MCE is delegating to a subcontractor:

(A) The subcontract must specify the delegated activities or obligations, as well as any related reporting responsibilities;

(B) The subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCE’s contract obligations; and

(C) The subcontract must either provide for revocation of the delegation or specify other remedies in instances where the Authority or the MCE determines that the subcontractor has not performed satisfactorily.

(b) The subcontractor agrees to comply with all applicable state and federal statutes, rules, regulations, executive orders and sub-regulatory guidance, as well as any and all other applicable requirements in the MCE contract:

(A) The subcontractor agrees to comply with Section C Part 10 of Attachment D of the 2022-2027 Medicaid 1115 Waiver regarding timely Payment to IHCP Providers;

(B) Timely payments means that IHCPs must be paid the agreed upon rate within 30-90 calendar days of billing;

(c) The subcontractor agrees to perform any activities necessary to support the MCE and the Authority’s obligations as specified in the MCE contract, state and federal statutes, rules, regulations, and sub-regulatory guidance.

(A) This includes, but is not limited to, requirements related to:

(i) Program integrity and data submission, including the requirements in 42 CFR, Part 438, Subpart H;

(ii) Grievances and appeals, including the requirements in 42 CFR, Part 438, Subpart F;

(iii) Exclusions, as noted in 42 CFR § 438.808; and

(iv) Linguistic and disability access for members, as outlined in 42 CFR § 438.10, as well as 42 U.S.C. § 18116 and 45 CFR Part 92.

(B) Any other activities that may be required under state and federal statutes, rules, regulations, and sub-regulatory guidance.

(3) In addition to all of the requirements set out in section (2) above of this rule, an MCE subcontract with a dental subcontractor must also include the following terms and conditions:

(a) Clearly define the activities the MCE is delegating to the dental subcontractor, including activities related to the provision of Covered Services and to the dental subcontractor’s fitness to enter into a subcontract under state and federal law and rule;

(b) Require a dental subcontractor to provide any and all reports, documents, or other information, or any combination thereof, that the MCE is required to provide under its contract with OHA, under this OAR chapter 410, and as may be additionally required under state and federal statutes, rules, regulations, executive orders and sub-regulatory guidance; and

(c) Dental subcontractor must agree to the delegated activities, related requirements and the associated compensation through a signed agreement before MCE can include dental subcontractor on its list of subcontractors to be submitted to OHA.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3510 Provider Contracting and Credentialing

(1) Managed Care Entity’s (MCEs) shall develop policies and procedures for credentialing providers to include quality standards and a process to remove providers from their provider network if they fail to meet the objective quality standards.

(a) MCEs shall ensure that all participating providers as defined in OAR 410-141-3500 providing coordinated care services to members are credentialed upon initial contract with the MCE and re-credentialed as follows:

(A) If the provider is credentialed or recredentialed on the 1st of a month, within three (3) years of that date; or

(B) If the provider is credentialed or recredentialed on a day other than the 1st of a month, within three (3) years from the 1st of the month that follows the month in which the provider was credentialed or recredentialed.

(b) The credentialing and re-credentialing process shall include review of any information in the National Practitioners Databank. MCEs shall accept both the Oregon Practitioner Credentialing Application and the Oregon Practitioner Recredentialing Application;

(c) MCEs shall screen their participating providers to be in compliance with 42 CFR 455 Subpart E (42 CFR 455.410 through 42 CFR 455.470) and retain all resulting documentation for audit purposes, except in the following circumstances for credentialing COVID-19 vaccine administration providers for the sole purpose of administering COVID-19 vaccines or the administration of the flu vaccine when administered in conjunction with the COVID-19 vaccination. For the purpose of this rule, COVID-19 vaccination administration provider means a healthcare provider that has successfully enrolled with the Authority’s Public Health Division to be a COVID-19 vaccination administration provider, completed all required training, and has agreed to all terms of program participation.

(A) MCEs may rely upon the most recent weekly update of the Authority’s active file of vaccine administration providers to meet contractual and regulatory requirements for credentialing COVID-19 vaccine administration providers.

(B) MCEs may enroll COVID-19 vaccine administration providers who are included in the Authority’s most recent active file of vaccine administration providers.

(C) MCEs shall monitor changes in the Authority’s weekly active file of vaccine administration providers for terminations and changes.

(d) MCEs shall screen their contracted HRSN Service Providers to be in compliance with 42 CFR §§ 455.410 through 455.436, 455.450, 455.452, and 455.470, and retain all resulting documentation for audit purposes.

(e) MCEs may elect to contract for or delegate responsibility for the credentialing and screening processes; however, MCEs shall be solely and ultimately responsible for adhering with all terms and conditions held in its contract with the state. For the following activities including oversight of the following processes regardless of whether the activities are provided directly, contracted, or delegated, MCEs shall:

(A) Ensure that coordinated care services are provided within the scope of license or certification of the participating provider or facility and within the scope of the participating provider’s contracted services. They shall ensure participating providers are appropriately supervised according to their scope of practice;

(B) Provide training for MCE staff and participating providers and their staff regarding the delivery of coordinated care services, applicable administrative rules, and the MCEs administrative policies.

(f) The MCE shall provide accurate and timely information to the Authority about:

(A) License or certification expiration and renewal dates;

(B) Whether a provider’s license or certification is expired or not renewed or is subject to licensing termination, suspension, or certification sanction;

(C) If an MCE knows or has reason to know that a provider has been convicted of a felony or misdemeanor related to a crime or violation of federal or state laws under Medicare, Medicaid, or Title XIX (including a plea of “nolo contendere”);

(D) If an MCE removes a provider or fails to renew a provider’s contract if the provider fails to meet objective quality standards.

(g) MCEs may not refer members to or use providers that:

(A) Have been terminated from Medicaid;

(B) Have been excluded as a Medicaid provider by another state;

(D) Are subject to exclusion for any lawful conviction by a court for which the provider may be excluded under 42 CFR 1001.101.

(h) MCEs may not accept billings for services to members provided after the date of the provider’s exclusion, conviction, or termination. MCEs shall recoup any monies paid for services to members provided after the date of the provider’s exclusion, conviction, or termination;

(i) MCEs shall require each atypical provider to be enrolled with the Authority. MCEs shall also require each atypical provider, except HRSN Service Providers, unless that HRSN Service Provider is a licensed and credentialed professional authorized to bill Medicaid, to obtain and use registered National Provider Identifiers (NPIs), and taxonomy codes reported to the Authority in the Provider Capacity Report for purposes of encounter data submission prior to submitting encounter data in connection with services by the provider. MCEs shall require each qualified provider, except HRSN Service Providers, to have and use an NPI as enumerated by the National Plan and Provider Enumeration System (NPPES);

(j) The provider enrollment request (for encounter purposes) and credentialing documents require the disclosure of taxpayer identification numbers. The Authority shall use taxpayer identification numbers for the administration of this program including provider enrollment, internal verification, and administrative purposes for the medical assistance program for administration of tax laws. The Authority may use taxpayer identification numbers to confirm whether the individual or entity is subject to exclusion from participation in the medical assistance program. Taxpayer identification number includes Employer Identification Number (EIN), Social Security Number (SSN), and Individual Tax Identification Number (ITIN) used to identify the individual or entity on the enrollment request form or disclosure statement. Disclosure of all tax identification numbers for these purposes is mandatory. Failure to submit the requested taxpayer identification numbers may result in denial of enrollment as a provider and denial of a provider number for encounter purposes or denial of continued enrollment as a provider and deactivation of all provider numbers used by the provider for encounters.

(2) An MCE may not discriminate with respect to participation in the MCE against any health care provider who is acting within the scope of the provider’s license or certification under applicable state law on the basis of that license or certification. If an MCE declines to include individual or groups of providers in its network, it shall give the affected providers written notice of the reason for its decision. This rule may not be construed to:

(a) Require that an MCE contract with any health care provider willing to abide by the terms and conditions for participation established by the MCE; or

(b) Preclude the MCE from establishing varying reimbursement rates based on quality or performance measures. For purposes of this section, quality and performance measures include all factors that advance the goals of health system transformation including:

(A) Factors designed to maintain quality of services and control costs and are consistent with its responsibilities to members; or

(B) Factors that add value to the service provided including but not limited to expertise, experience, accessibility, or cultural competence.

(c) The requirements in subsection (2)(b) of this rule do not apply to reimbursement rate variations between providers with the same license or certification or between specialists and non-specialty providers.

(3) An MCE shall establish an internal review process for a provider aggrieved by a decision under section (2) of this rule including an alternative dispute resolution or peer review process. An aggrieved provider may appeal the determination of the internal review to the Authority.

(4) To resolve appeals made to the Authority under sections (2) and (3) of this rule, the Authority shall provide administrative review of the provider’s appeal using the administrative review process established in OAR 410-120-1580. The Authority shall invite the aggrieved provider and the MCE to participate in the administrative review. In making a determination of whether there has been discrimination, the Authority shall consider the MCE’s:

(a) Network adequacy;

(b) Provider types and qualifications;

(d) Provider reimbursement rates.

(5) A prevailing party in an appeal under sections (3) through (4) of this rule shall be awarded the costs of the appeal.

(6) MCEs shall not apply any requirement that any entity operated by the IHS, an Indian tribe, tribal organization or urban Indian organization be licensed or recognized under the State or local law where the entity is located to furnish health care services, if the entity meets all the applicable standards for such licensure or recognition. This requirement is pursuant to 25 USC 1621t and 1647a.

(7) MCEs shall not require the licensure of a health professional employed by such an entity under the State or local law where the entity is located, if the professional is licensed in another State.

(8) MCEs shall offer contracts to all Medicaid eligible IHCPs and to provide timely access to specialty and primary care within their networks to MCE enrolled IHS beneficiaries seen and referred by IHCPs, regardless of the IHCPs status as contracted provider within the MCE network.

(9) MCEs shall ensure that all contracted HRSN Service Providers meet the specific provider qualifications to provide HRSN Services to HRSN Authorized Members as described in OAR-410-120-2030.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065, 414.572, 414.605, 414.632, 414.665 & 414.719
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 130-2024, amend filed 10/24/2024, effective 11/01/2024
DMAP 118-2024, amend filed 08/26/2024, effective 08/26/2024
DMAP 85-2024, temporary amend filed 04/05/2024, effective 04/05/2024 through 08/27/2024
DMAP 74-2024, temporary amend filed 03/01/2024, effective 03/01/2024 through 08/27/2024
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 47-2021, temporary amend filed 10/26/2021, effective 10/27/2021 through 04/24/2022
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 10-2021, temporary amend filed 03/15/2021, effective 03/15/2021 through 09/10/2021
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3515 Network Adequacy

(1) CCOs shall maintain and monitor a network of participating providers that is sufficient in number, provider type, and geographic distribution to ensure adequate service capacity and availability to provide available and timely access to medically appropriate and culturally responsive covered services to both current members and those the CCO anticipate shall become enrolled as members.

(2) The CCO shall develop a provider network that enables members to access services within the standards defined in this rule.

(3) The CCO shall meet access-to-care standards that allow for appropriate choice for members. Services and supports shall be as close as possible to where members reside and, to the extent necessary, offered in nontraditional settings that are accessible to families, diverse communities, and underserved populations.

(4) CCOs shall meet quantitative network access standards defined in rule and contract.

(5) CCOs shall ensure access to integrated and coordinated care as outlined in OAR 410-141-3860, which includes access to a primary care provider or primary care team that is responsible for coordination of care and transitions.

(6) In developing its provider network, the CCOs shall anticipate access needs so that the members receive the right care at the right time and place, using a patient-centered, trauma informed approach. The provider network shall support members, especially those with behavioral health conditions, in the most appropriate and independent setting, including in their own home or independent supported living.

(7) In assessing the capacity and adequacy of its provider network, CCOs shall consider, in conjunction with the quantitative standards set forth in this rule, the variety of provider and facility types with the demonstrated ability and expertise to render specific medically or dentally appropriate covered services within the scope of applicable licensing and credentialling. This includes, but is not limited to, the prescribing of Medication-Assisted Treatment and more specialized oral health care services.

(8) All CCOs shall ensure 95 percent of members can access the following provider and facility types, further defined by the Authority in guidance made available on the CCO Contracts Forms webpage https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx, within acceptable travel time or distance standards set forth this rule:

(a) Tier one:

(A) Primary care providers serving adults and those serving pediatrics;

(B) Primary care dentists serving adults and those serving pediatrics;

(D) Substance use disorder providers serving adults and those serving pediatrics;

(E) Pharmacy;

(F) Additional provider types when it promotes the objectives of the Authority or as required by legislation.

(b) Tier two:

(A) Obstetric and gynecological service providers;

(B) The following specialty providers, serving adults and those serving pediatrics;

(i) Cardiology;

(ii) Neurology;

(iii) Occupational Therapy;

(iv) Medical Oncology;

(v) Radiation Oncology;

(vi) Ophthalmology;

(vii) Optometry;

(viii) Physical Therapy;

(ix) Podiatry;

(x) Psychiatry;

(xi) Speech Language Pathology.

(D) Durable medical equipment;

(E) Methadone Clinic;

(F) Additional provider types when it promotes the objectives of the Authority or as required by legislation.

(A) The following specialty providers, serving adults and those serving pediatrics;

(i) Allergy & Immunology;

(ii) Dermatology;

(iii) Endocrinology;

(iv) Gastroenterology;

(v) Hematology;

(vi) Nephrology;

(vii) Otolaryngology;

(viii) Pulmonology;

(ix) Rheumatology;

(x) Urology.

(B) Post-hospital skilled nursing facilities;

(9) All CCO acceptable travel time and distance monitoring must assess the geographic distribution of providers relative to members and calculate driving time and distance from the member’s physical address to the provider’s location through the use of geocoding software or other mapping applications. The Authority shall provide tools and additional guidance specific to time and distance monitoring on the CCO Contracts Forms webpage https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(a) A CCO service area may contain multiple geographic designations. When calculating travel time and distance, geographic designations must not overlap and the following definitions of geographic designations shall apply:

(A) Large urban area: Conjoined urban areas with a total population of at least 1 million people or with a population density greater than 1,000 people per square mile.

(B) Urban area: An area with greater than 40,000 people within a 10 mile radius of a city center.

(D) County with extreme access considerations: County with a population density of 10 or fewer people per square mile.

(b) When calculating travel time and distance, CCOs shall use the following standards:

(A) Large Urban Area:

(i) Tier one: 10 minutes or 5 miles;

(ii) Tier two: 20 minutes or 10 miles;

(iii) Tier three: 30 minutes or 15 miles.

(B) Urban Area:

(i) Tier one: 25 minutes or 15 miles;

(ii) Tier two: 30 minutes or 20 miles;

(iii) Tier three: 45 minutes or 30 miles.

(i) Tier one: 30 minutes or 20 miles;

(ii) Tier two: 75 minutes or 60 miles;

(iii) Tier three: 110 minutes or 90 miles.

(D) County with Extreme Access Considerations:

(i) Tier one: 40 minutes or 30 miles;

(ii) Tier two: 95 minutes or 85 miles;

(iii) Tier three: 140 minutes or 125 miles.

(10) CCOs may request an exception to a standard set in (8) and (9) of this rule. CCOs may request multiple exceptions.

(a) Exception requests must be submitted in a format provided by the Authority and made available on the CCO Contract Forms webpage https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(b) The Authority shall review and approve or deny exception requests based on criteria made available on the CCO Contracts Forms webpage. Approved exceptions must be reviewed at least annually.

(11) OHA may grant exceptions to the standards set in (8) and (9) of this rule when enrollment capacity is increased.

(12) CCOs shall have an access plan that establishes a protocol for monitoring and ensuring access, outlines how provider capacity is determined, and establishes procedures for monthly monitoring of capacity and access and for improving access and managing access in times of reduced participating provider capacity. The access plan and associated monitoring protocol shall address the following:

(a) Expected utilization of services based on anticipated member enrollment and health care needs of the member population;

(b) The number and types of providers required to furnish the contracted services based on the expected utilization of services referenced above and the number and types of providers actively providing services within the CCO’s current provider network;

(c) How the CCO shall meet the accommodation and language needs of individuals with LEP as defined in OAR 410-141-3500 and people with disabilities in their service area in compliance with state and federal rules including but not limited to ORS 659A, Title VI of the Civil Rights Act of 1964, Section 1557 of the Affordable Care Act, the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act of 1973;

(d) The availability of telemedicine within the CCO’s contracted provider network.

(13) CCOs shall make the services it provides (including primary care, specialists, pharmacy, hospital, vision, ancillary, and behavioral health services or other services as necessary to achieve compliance with the requirements of 42 CFR 438, subpart K) as accessible to members for timeliness, amount, duration, and scope as those services are to other patients within the same service area. If the CCO is unable to provide those services through the use of participating providers qualified and specialized to treat a member’s condition, it must arrange for the member to access care from non-participating providers as geographically close to the member as possible, including providers outside the service area.

(14) CCOs shall have policies and procedures and a monitoring system to ensure that members who are aged, blind, or disabled, or who have complex or high health care needs, multiple chronic conditions, or have behavioral health conditions, or who are children receiving Department or Oregon Youth Authority (OYA) services have access to primary care, oral care (when the CCO is responsible for oral care), behavioral health providers, and referral, and involve those members in accessing and managing appropriate preventive, health, remedial, and supportive care and services. CCOs shall monitor and have policies and procedures to ensure:

(a) Access to providers of pharmacy, hospital, vision, ancillary, and behavioral health services;

(b) Priority access for pregnant women and children ages birth through five (5) years to health services, developmental services, early intervention, targeted supportive services, oral and behavioral health treatment.

(15) CCOs shall have policies and procedures that ensure scheduling and rescheduling of member appointments are appropriate to the reasons for and urgency of the visit. The member shall be seen, treated, or referred within the following timeframes:

(a) Physical health:

(A) Emergency care: Immediately or referred to an emergency department depending on the member’s condition;

(B) Urgent care: Within 72 hours or as indicated in initial screening and in accordance with OAR 410-141-3840;

(C) Well care: Within four (4) weeks, or as otherwise required by applicable care coordination rules, including OAR 410-141-3860 through 410-141-3870.

(b) Oral and Dental care for children and non-pregnant individuals:

(A) Dental Emergency services as defined in OAR 410-120-0000: Seen or treated within 24 hours;

(B) Urgent dental l care: Within two (2) weeks;

(C) Routine oral care: Within eight (8) weeks, unless there is a documented special clinical reason that makes a period of longer than eight (8) weeks appropriate.

(A) Dental Emergency services. Seen or treated within 24 hours;

(B) Urgent dental care, within one (1) week;

(C) Routine oral care: Within four (4) weeks, unless there is a documented special clinical reason that must make access longer than four (4) weeks appropriate.

(d) Behavioral health:

(A) Urgent behavioral health care for all populations: Within 24 hours;

(B) Specialty behavioral health care for priority populations:

(i) In accordance with the timeframes listed in this rule for assessment and entry, terms are defined in OAR 309-019-0105, with access prioritized per OAR 309-019-0135. If a timeframe cannot be met due to lack of capacity, the member must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. Interim services must be comparable to the original services requested based on the level of care and may include referrals, methadone maintenance, HIV/AIDS testing, outpatient services for substance use disorder, risk reduction, residential services for substance use disorder, withdrawal management, and assessments or other services described in OAR 309-019-0135;

(ii) Pregnant women, veterans and their families, women with children, unpaid caregivers, families, and children ages birth through five years, individuals with HIV/AIDS or tuberculosis, individuals at the risk of first episode psychosis and the I/DD population: Immediate assessment and entry. If interim services are necessary due to capacity restrictions, treatment at appropriate level of care must commence within 120 days from placement on a waitlist;

(iii) IV drug users including heroin: Immediate assessment and entry. Admission for treatment in a residential level of care is required within fourteen (14) days of request, or, if interim series are necessary due to capacity restrictions, admission must commence within 120 days from placement on a waitlist;

(iv) Opioid use disorder: Assessment and entry within 72 hours;

(v) Medication assisted treatment: As quickly as possible, not to exceed 72 hours for assessment and entry;

(vi) Children with serious emotional disturbance as defined in OAR 410-141-3500: Any limits that the Authority may specify in the contract or in sub regulatory guidance.

(C) Routine behavioral health care for non-priority populations: Assessment within seven days of the request, with a second appointment occurring as clinically appropriate.

(16) CCOs shall implement procedures for communicating with and providing care to members who have difficulty communicating due to a medical condition, who need accommodation due to a disability, or, as detailed in OAR chapter 950, division 050 for those who have Limited English Proficiency, prefer to communicate in a language other than English or who communicates in signed language.

(a) The policies and procedures shall ensure the provision of Oregon certified or Oregon qualified interpreter services by phone or in person anywhere the member is attempting to access care or communicate with the CCO or its representatives;

(b) CCOs shall ensure the provision of certified or qualified interpreter services for all covered services to interpret for members with hearing impairment or in the primary language of non-English-speaking members;

(c) All interpreters must be linguistically appropriate and capable of communicating in both English and the member’s primary language and be able to translate clinical information effectively. Interpreter services must enable the provider to understand the member’s complaint, make a diagnosis, respond to the member’s questions and concerns, and communicate instructions to the member;

(d) CCOs shall ensure the provision of services that are culturally appropriate as described in National CLAS Standards, demonstrating both awareness for and sensitivity to cultural differences and similarities and the effect on the member’s care. CCOs shall ensure the provision of Oregon certified or Oregon qualified interpreters.

(e) CCOs shall comply with requirements of the Americans with Disabilities Act of 1990, as amended via the ADA Amendments Act of 2008, in providing access to covered services for all members and shall arrange for services to be provided by non-participating providers when necessary;

(f) CCOs shall collect and actively monitor data on language accessibility to ensure compliance with these language access requirements;

(g) CCOs shall report to the Authority such language access data and other language access related analyses in the form and manner set forth in this rule and as may otherwise be required in the CCO contract. The Authority shall provide supplemental instructions about the use of any required forms:

(A) Using the interpreter services self-assessment reporting template provided by the Authority, CCOs shall conduct an annual language access self-assessment and submit the completed language access self-assessment to the Authority on or before the third Monday of each January;

(B) CCOs shall collect and report language access and interpreter services to the Authority using the report form provided by the Authority. The due dates for the report are April 1 and October 1 in each calendar year. Each report shall include data for the twelve (12) months ending one quarter before the due date.

(C) CCOs shall complete and submit to the Authority any other language access reporting that may be required in the CCO contract.

(17) CCOs shall collect and actively monitor data on provider-to-enrollee ratios, interpretation utilization by the CCO and the CCO’s provider network, travel time and distance to providers, percentage of contracted providers accepting new members, wait times to appointment (including specific data for behavioral health wait times), and hours of operation. CCOs shall also collect and actively monitor data on call center performance and accessibility for both member services and NEMT brokerage services call centers.

(18) CCOs must submit a Delivery System Network (DSN) report annually to the Authority that includes access data and other access-related analyses in the form and manner required by the Authority, including but not limited to capacity reports on:

(a) Behavioral health access;

(b) Interpreter utilization by the CCO’s provider network;

(19) CCOs shall report the methodology for monitoring network adequacy to the Authority and the Authority-contracted External Quality Review Organization (EQRO).

(20) CCOs shall implement and require its providers to adhere to the following appointment and wait time requirements:

(a) A member may request to reschedule an appointment if the wait time for a scheduled appointment exceeds 30 minutes. If the member requests to reschedule, they must not be penalized for failing to keep the appointment;

(b) CCOs shall implement written procedures and a monitoring system for timely follow-up with members when a participating provider has notified the CCO that the member failed to keep scheduled appointments. The procedures shall address:

(A) Timely rescheduling of missed appointments, as deemed medically appropriate;

(B) Documentation in the clinical record or non-clinical record of missed appointments;

(D) Method of member follow-up.

(c) If failure to keep a scheduled appointment is a symptom of the member’s diagnosis or disability or is due to lack of transportation to the CCO’s participating provider office or clinic, or lack of interpreter services, CCOs shall provide outreach services and offer Care Coordination as medically appropriate to make a plan with the member to resolve barriers;

(d) Recognition of whether NEMT services were the cause of the member’s missed appointment.

(21) CCOs shall assess the needs of their membership and make available supported employment and Assertive Community Treatment services when members are referred and eligible:

(a) CCOs shall report the number of individuals who receive supported employment and assertive community treatment services, at a frequency to be determined by the Authority. When no appropriate provider is available, the CCO shall consult with the Authority and develop an approved plan to make supported employment and Assertive Community Treatment (ACT) services available;

(b) If ten (10) or more members in a CCO region have been referred, are eligible, and are appropriate for assertive community treatment, and have been on a waitlist to receive ACT for more than thirty (30) days, CCOs shall notify the Authority and take action to reduce the waitlist and serve those individuals by:

(A) Increasing team capacity to a size that is still consistent with fidelity standards; or

(B) Adding additional Assertive Community Treatment teams; or

(C) When no appropriate ACT provider is available, the CCO shall consult with the Authority and develop an approved plan to increase capacity and add additional teams.

(22) HRSN Service Provider Minimum Network Requirements.

(a) A CCO must offer HRSN Services in all service areas in which the CCO operates.

(b) The CCO must ensure that HRSN Services are delivered to Members within the timelines outlined in OAR 410-120-2020.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 101-2025, temporary amend filed 12/30/2025, effective 01/02/2026 through 06/30/2026
DMAP 40-2025, amend filed 04/25/2025, effective 05/01/2025
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 130-2024, amend filed 10/24/2024, effective 11/01/2024
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 86-2023, amend filed 12/13/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3520 Record Keeping and Use of Health Information Technology

(1) MCEs shall have written policies and procedures that ensure maintenance of a record keeping system that includes maintaining the security of records as required by the Health Insurance Portability and Accountability Act (HIPAA), 42 USC §1320-d et seq., the federal regulations implementing the Act, and complete clinical records that document the coordinated care services received by the members. MCEs shall communicate these policies and procedures to subcontractors. MCEs shall regularly monitor its subcontractors’ compliance and take any corrective action necessary. MCEs shall document all monitoring and corrective action activities. These policies and procedures shall ensure that records are secured, safeguarded, and stored in accordance with applicable Oregon Revised Statutes and Oregon Administrative Rules. A member must have access to the member’s personal health information in the manner provided in 45 C.F.R. 164.524 and ORS 179.505(9) so the member may share the information with others involved in the member’s care and make better health care and lifestyle choices.

(2) MCE’s participating providers may charge the member for reasonable duplication costs, as set forth in OAR 943-014-0030, when the member requests copies of their records.

(3) Notwithstanding ORS 179.505, an MCE, its provider network, and programs administered by the Department’s Aging and People with Disabilities shall use and disclose member information for purposes of service and care delivery, coordination, service planning, transitional services, and reimbursement in order to improve the safety and quality of care, lower the cost of care, and improve the health and well-being of the members.

(4) An MCE and its provider network shall use and disclose sensitive diagnosis information including HIV and other health and behavioral health diagnoses within the MCE for the purpose of providing whole-person care. Individually identifiable health information must be treated as confidential and privileged information subject to ORS 192.553 to 192.581 and applicable federal privacy requirements. Re-disclosure of individually identifiable information outside of the MCE and the MCE’s providers for purposes unrelated to this section or the requirements of ORS 414.625, 414.632, 414.635, 414.638, 414.653 and 414.655 remains subject to any applicable federal or state privacy requirements including the Authority’s rules established in OAR 943-014-0000 through 0070 for matters that involve privacy and confidentiality and privacy of members protected information.

(5) The MCE must document its methods and findings to ensure across the organization and the network of providers there is documentation of the coordinated care services and supports, including transitions of care and access to preventive and wellness services.

(6) MCEs shall support the adoption and use of electronic health records (EHRs) by its provider network, including physical, behavioral, and oral health providers. To achieve EHR adoption, MCEs shall:

(a) Identify EHR adoption rates, divided by provider type (at a minimum, divided by physical, behavioral, and oral health) and geographic region if applicable;

(b) Develop and implement strategies to increase adoption rates of EHRs among all provider types; and

(7) MCEs shall support access to electronic health information exchange (HIE) for care coordination and hospital event notifications for contracted physical, behavioral, and oral health providers. To achieve improved HIE access rates, MCEs shall:

(a) Identify current and monitor ongoing HIE adoption rates, divided by provider type (at a minimum, divided by physical, behavioral, and oral health) and geographic region if applicable;

(b) Develop and implement strategies to increase access to HIE among all provider types;

(d) Ensure that providers have access to hospital event notifications. The MCE shall itself use hospital event notifications as appropriate to support care coordination and population health efforts.

(8) MCEs shall maintain health information systems that collect, analyze, integrate, and report data at an individualized member level concerning the provision of covered services and CCO administrative functions, such as enrolment/disenrollment and resolution of grievances and appeals. Based on written policies and procedures, the record keeping system developed and maintained by MCEs and their participating providers shall include sufficient detail and clarity to permit internal and external review to validate encounter submissions and to assure medically appropriate services are provided consistent with the documented needs of the member.

(9) MCEs and their provider network shall cooperate with the Authority, the Department of Justice Medicaid Fraud Control Unit (MFCU), and CMS or other authorized state or federal reviewers for purposes of audits, inspection, and examination of members' clinical records, whether those records are maintained electronically or in physical files. Documentation must be sufficiently complete and accurate to permit evaluation and confirmation that coordinated care services are authorized and provided, referrals are made, and outcomes of coordinated care and referrals are sufficient to meet professional standards applicable to the health care professional and meet the requirements for health oversight and outcome reporting in these rules.

(10) Across the MCE’s provider network, all clinical records shall be retained for a minimum of 10 years after the date of services for which claims are made. MCEs shall maintain any other records, books, documents, papers, plans, records of shipments, and payments and writings, whether in paper, electronic, or other form that are pertinent in a manner that clearly documents the MCE’s performance. All clinical records, financial records, other records, books, documents, papers, plans, records of shipments, and payments and writings of the MCE whether in paper, electronic, or other form are collectively referred to as “Records.” If an audit, litigation, research and evaluation, or other action involving the records is started before the end of the ten-year period, the clinical records must be retained until all issues arising out of the action are resolved.

(11) MCEs shall allow access to the agencies listed in section (9) of all audit records and its subcontractors and participating provider’s records to allow the listed agencies to perform examinations and audits and make excerpts and transcripts and to evaluate the quality, appropriateness, and timeliness of services.

(12) MCEs shall allow access to the entities listed in section (9) at any time to inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. MCEs subject to an audit under this section shall retain records for 10 years from the final date of the contract period or from the date of completion of the most recent state audit, whichever is later. MCEs shall retain and keep accessible all records for a minimum of 10 years. County agencies participating in the Medicaid program are subject to whichever record retention requirement is longer between this rule and OAR chapter 166, division 150 County and Special District Retention Schedule.

(13) MCEs must maintain yearly logs of all appeals and grievances for 10 years following requirements specified in OAR 410-141-3915.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3525 Outcome and Quality Measures

(1) Managed Care Entities (MCEs) shall report to the Authority its health promotion and disease prevention activities, national accreditation organization results, and Healthcare Effectiveness Data and Information Set (HEDIS) measures as required by DCBS in OAR 836-053-1000. A copy of the reports may be provided to the Authority's Performance Improvement Coordinator concurrent with any submission to DCBS.

(2) The MCE shall inform the Authority if it has been accredited by a private independent accrediting entity. If the MCE has been so accredited, the MCE shall authorize the private independent accrediting entity to provide the Authority a copy of its most recent accreditation review in accordance with CFR 42 CFR §438.332.

(3) As required by health system transformation, MCEs shall be accountable for performance on outcomes, quality, and efficiency measures incorporated into the MCE's contract with the Authority. Measures are selected by the Authority with the incentive measures specifically adopted by the Metrics and Scoring Committee using a public process. Information can be requested from the Authority or viewed online at the Metrics and Scoring Committee website located at https://www.oregon.gov/oha/HPA/ANALYTICS/Pages/CCO-Metrics.aspx.

(4) MCEs shall address objective outcomes, quality measures, and benchmarks for ambulatory care, inpatient care, behavioral health care, dental services, HRSN Services and all other health services provided by or under the responsibility of the MCE as specified in the MCE's contract with the Authority and federal external quality review requirements in CFR 42 §438.350, §438.358, and §438.364.

(5) MCEs shall implement an ongoing comprehensive quality assessment and performance improvement program (QAPI) for monitoring, evaluating, and improving the access, quality, and appropriateness of services provided to members consistent with the needs and priorities identified in the MCE's community health assessment, community health improvement plan, and the standards in the MCE's contract. This process shall include an internal Quality Improvement (QI) program with written criteria based on written policies, evidenced-based practice guidelines, standards and procedures that are in accordance with the requirements set forth in 42 CFR §438.330, relevant law and the community standards for care, or in accordance with accepted medical practice, whichever is applicable, and with accepted professional standards. MCEs shall have in effect mechanisms to:

(a) Detect both underutilization and overutilization of services;

(b) Evaluate performance and customer satisfaction consistent with MCE contractual requirements, relevant Oregon Administrative Rules, and provide documentation of implementation of interventions to achieve improvement in the access to and quality of care to the Authority and the Authority contracted External Quality Review Organization (EQRO);

(d) Assess the quality and appropriateness of coordinated care services provided to all members with identified special health care needs including those who are aged, blind, or disabled or who have high health care needs, multiple chronic conditions, behavioral health disorders; who receive Medicaid funded long-term care or long-term services and supports benefits; or who are children receiving Child Welfare services or OYA services; and

(e) Report on the diversity and capacity of the workforce in their service area including capacity to provide services in a culturally responsive and trauma informed manner, appropriately relying on workforce data provided by the Authority;

(f) Undertake performance improvement projects that are designed to improve the access, quality and utilization of services. Projects must be designed to achieve significant improvement in health outcomes and member satisfaction.

(6) MCEs shall implement policies and procedures that assure the timely collection of data including health disparities and other data required by rule or contract (or both) that allows the MCE to conduct and report on its outcome and quality measures and report its performance. MCEs shall submit to the Authority the MCE's annual written evaluation of outcome and quality measures established for the MCE or other reports as the Authority may require in response to the measures adopted by the Metrics and Scoring Committee; including but not limited to output from Electronic Health Records, Chart Reviews, Claim validation reports and other materials required for final assessment of relevant measures and within established deadlines.

(7) MCEs shall adopt practice guidelines consistent with 42 CFR § 438.236 and the MCE contract that addresses assigned contractual responsibilities for physical health care, behavioral health care, and/or dental services ; goals to increase care coordination with other MCEs, the state, or other providers as outlined in OAR 410-141-0160 and 410-141-3860; and concerns identified by members or their representatives and to implement changes that have a favorable impact on health outcomes and member satisfaction in consultation with its community advisory council or clinical review panel.

(8) MCEs shall be accountable for both core and transformational measures of quality and outcomes:

(a) Core measures shall be triple-aim oriented measures that gauge MCE performance against key expectations for care coordination, consumer satisfaction, quality, and outcomes. The measures shall be uniform across MCEs and shall encompass the range of services included in MCE global budgets (e.g., behavioral health, hospital care, women's health). Core measures may be defined as typical standardized medical-centric measures such as The National Committee of for Quality Assurance's (NCQAs) Electronic Clinical Quality Measures (eCQM) and Healthcare Effectiveness Data and Information Set (HEDIS) that have state or national normative statistics;

(b) Transformational metrics shall assess MCE progress toward the broad goals of health system transformation. This subset may include newer kinds of indicators (for which MCEs have less measurement experience) or indicators that entail collaboration with other care partners, such as social service agencies or other community support services. Additional areas of transformational measures may include culturally informed care, health equity or Flexible Services (per OAR 410-141-3845) not typically associated with medical care. Transformational metrics shall also require cooperation from MCEs for pilot or demonstration activities as these newly formed measures are developed over time. Development of different evaluation criteria for acceptance by the metrics selection committees for use by MCEs may also be necessary for transformational metrics.

(9) MCEs shall provide the required data to the All Payer All Claims data system established in ORS 442.372 and 442.373 and the MCE agreement in the manner authorized by OAR 409-025-0130.

(10) The positions of Medical or Dental Director and the QI Coordinator shall have the qualifications, responsibility, experience, authority, and accountability necessary to assure compliance with this rule. MCEs shall designate a QI Coordinator who shall develop and coordinate systems to facilitate the work of the QI Committee. The QI Coordinator is generally responsible for the operations of the QI program and must have the management authority to implement changes to the QI program as directed by the QI Committee. The QI Coordinator shall be qualified to assess the care of Authority members including those who are eligible for intensive care coordination (ICC) services under OAR 410-141-3870 or shall be able to retain consultation from individuals who are qualified.

(11) MCEs shall establish a QI Committee that shall meet at least every two months. The Committee shall retain authority and accountability to the Board of Directors for the assurance of quality of care. Committee membership shall include, but is not limited to, the Medical or Dental Director, the QI Coordinator, and other health professionals who are representative of the scope of the services delivered. If any QI functions are delegated, the QI Committee shall maintain oversight and accountability for those delegated functions. The QI Committee shall:

(a) Approve the MCE annual quality strategy and retain oversight and accountability of quality efforts and activities performed by other MCE committees including the following: implementation of the annual quality strategy, a work plan that incorporates implementation of system improvements, and an internal utilization review oversight committee that monitors utilization against practice guidelines and Treatment Planning protocols and policies;

(b) Record and produce dated minutes of Committee deliberations. Document recommendations regarding corrective actions to address issues identified through the QI Committee review process, and review of results, progress, and effectiveness of corrective actions recommended at previous meetings. These records and minutes shall be made available to relevant Authority quality staff, upon request;

(c) MCEs shall conduct and submit to the Authority an annual written evaluation of the QI Program and of member care as measured against the written procedures and protocols of member care. The evaluation of the QAPI program and member care is to include an assessment of annual activities conducted which includes background and rationale, a plan of ongoing improvement activities to address gaps which shall ensure quality of care for MCE members and overall effectiveness of the QI program. MCEs shall submit their evaluations to the Authority contracted External Quality Review Organization (EQRO). The MCEs shall follow the Transformation and Quality Strategy as outlined in the MCE contract for the QAPI and transformational care annual evaluation criteria;

(d) Conduct a quarterly review and analysis of all complaints and appeals received including a focused review of any persistent and significant member complaints and appeals as required in OAR 410-141-3915;

(e) Review written procedures, protocols and criteria for member care no less than every two (2) years, or more frequently as needed to maintain currency with clinical guidelines and administrative principles.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3530 Sanctions

(1) The Authority may establish and impose sanctions on Managed Care Entities (MCEs), pursuant to 42 CFR § 438.700, if the Authority makes a determination specified in paragraph (3) of this rule.

(2) The Authority may base its determinations on findings from onsite surveys, enrollee or other complaints, financial status, or any other source.

(3) The Authority may impose sanctions if the Authority determines that an MCE acts or fails to act as follows:

(a) Fails substantially to provide medically necessary services required under law or under its contract with the Authority to an enrollee covered under the contract;

(b) Imposes on enrollee’s premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program;

(c) Acts to discriminate among enrollees on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to re-enroll a beneficiary, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services;

(d) Misrepresents or falsifies information that it furnishes to the Centers for Medicare and Medicaid Services (CMS) or to the Authority;

(e) Misrepresents or falsifies information that it furnishes to an enrollee, potential enrollee, health care provider, or HRSN Service Provider;

(f) Fails to comply with the requirements for physician incentive plans, as set forth in 42 CFR §§ 422.208 and 422.210;

(g) Distributes directly or indirectly through any agent or independent contractor marketing materials that are not approved by the Authority or that contain false or materially misleading information;

(h) Violates any of the other applicable requirements of state or federal Medicaid law; or

(i) Fails to comply with any legal or contractual requirements that, pursuant to the MCE contract, may form a basis for sanctions.

(4) The Authority may impose a range of sanctions under this rule including the following:

(a) Civil monetary penalties in the amounts specified in section (5) of this rule;

(b) Appointment of temporary management for an MCE as permitted under 42 CFR 438.706;

(c) Granting members the right to terminate enrollment without cause and notifying the affected members of their right to disenroll;

(d) Suspension of all new enrollment, including default enrollment, after the date the Authority notifies the MCE of a determination of a violation of rule or contract requirements;

(e) Suspension of payment for members enrolled after the effective date of the sanction and until the Authority is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur;

(f) Additional sanctions available under Oregon Revised Statutes and Oregon Administrative Rules that address areas of noncompliance specified in section (3) of this rule or any additional areas of noncompliance.

(5) If the Authority imposes civil monetary penalties:

(a) The maximum civil monetary penalty the Authority may impose varies depending on the nature of the MCE’s action or failure to act, subject to the limits in 42 CFR § 438.704;

(b) The Authority may issue penalties as specified on a per event, per member impacted, or per day basis for the duration of noncompliance.

(6) Before imposing any sanctions, the Authority must give the affected MCE timely written notice that explains the following:

(a) The basis and nature of the sanction;

(b) Any appeal rights under this rule and any other appeal rights that the Authority elects to provide.

(7) Administrative review, and if requested mediation:

(a) Are available for review of sanction decisions in accordance with OAR 410-120-1580 and 410-141-3550;

(b) If the Authority determines that there is continued egregious behavior, or that such action is necessary to ensure the health or safety of members, the Authority may impose the sanction before an administrative review opportunity is provided.

(8) Before terminating an MCE’s contract for cause, the Authority must provide the MCE the opportunity for a pre-termination hearing. The Authority must do all of the following:

(a) Give the MCE written notice of its intent to terminate, the reason for termination, and the time and place of the hearing;

(b) After the hearing, give the MCE written notice of the decision affirming or reversing the proposed termination of the contract and for an affirming decision the effective date of termination;

(c) For an affirming decision, give enrollees of the MCE notice of the termination and information on their options for receiving Medicaid services following the effective date of termination.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3531 Sanctions for Failure to Comply with State or Federal Information Security or Privacy Laws

(1) Pursuant to 42 CFR §438.700, the Authority may impose sanctions on an MCE if the Authority makes a determination that an MCE failed to comply with any one or more of the following:

(a) The contractual requirements of accessing or using the Authority’s or State Data, Network and Information Systems and Information Assets; or

(b) The Health Insurance Portability and Accountability Act (HIPAA) and the federal regulations implementing the HIPAA Privacy and Security Rules as set forth in 45 CFR Parts 160 and 164; or

(d) The federal regulations implementing the HIPAA Transaction Rule as set forth in 45 CFR Part 162, and any other federal statutes or regulations relating to health information technology that may come into effect, including, without limitation, the 21st Century Cures Act and the Interoperability and Patient Access regulations; or

(e) The Authority’s rules for electronic data transactions in OAR 943-120-0100 through 943-120-0200.

(2) The Authority may impose one or more sanctions under this rule including, but not limited to. the following:

(a) Require the MCE, at its own expense, to engage an independent third-party to conduct one or more security audits and implement any remedies identified or recommended in the audit report(s);

(b) Suspension or termination of one or more MCE employee’s access to the Authority’s or State’s Data, Network Systems, or Information Assets, or termination of access to the Authority’s and the State’s Data, Network, and Information Assets;

(c) Require the MCE, at its own expense, to engage an independent third-party to conduct penetration testing of its network systems on a monthly or more frequent basis;

(d) Require the MCE, at its own expense, to engage an independent third-party to provide information privacy and security training to the MCE’s employees;

(e) Require the MCE to develop and implement a time specific plan for the correction of the identified area(s) of non-compliance under section (1) of this rule; or

(f) Additional sanctions available under OAR 410-141-3530 or any other Oregon Administrative Rule or any Oregon Revised Statute that address areas of noncompliance for an MCE’s contractual, statutory, or administrative rule obligations.

(3) The Authority shall have the right to impose one or more sanctions for the same violation depending on the nature of the noncompliance (e.g. number of members impacted, whether an authorized party was provided with or was able to obtain protected health information or other identifiable personal information, or was the result of gross negligence, willful or intentional misconduct), whether the violation has occurred before, or if the Authority determines that there has been continued egregious conduct.

(4) In the event the Authority determines an MCE should be subject to sanctions under this rule, the Authority shall comply with, as applicable, sections (5) – (8) of OAR 410-141-3530, relating to written notice, appeal, administrative review, mediation, and termination rights.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 56-2021, adopt filed 12/30/2021, effective 01/01/2022

Or. Admin. R. 410-141-3540 Member Protections

(1) In the event of a finding of MCE impairment by the Authority, or of a termination of the MCE contract, members of the MCE shall be offered disenrollment from the MCE and enrollment in accordance with the Authority’s rules.

(2) For the purpose of this section only, and only in the event of a finding of MCE impairment by the Authority or of a termination of the MCE contract, any covered health care service furnished within the state by a provider to a member of the impaired or terminated MCE shall be considered to have been furnished pursuant to a contract between the provider and the MCE with whom the member was enrolled when the services were furnished.

(3) Each contract between an MCE and a provider of health services shall provide that if the MCE fails to pay for covered health services as set forth in the contract, the member is not liable to the provider for any amounts owed by the MCE.

(4) If the contract between the contracting provider and the MCE has not been reduced to writing or fails to contain the provisions required by this rule, the member is not liable to the contracting provider for any amounts owed by the MCE.

(5) No contracting provider or agent, trustee or assignee of the contracting provider shall bill a member, send a member’s bill to a Collection Agency, or maintain a civil action against a member to collect any amounts owed by the MCE for which the member is not liable to the contracting provider in this rule and under 410-120-1280.

(6) Nothing in this section impairs the right of a provider to charge, collect from, and attempt to collect from or maintain a civil action against a member for any of the following:

(a) Health services not covered by the MCE, if a valid OHP Client Agreement to Pay for Health Services form OHP 3165, or facsimile, signed by the client, has been completed as described in OAR 410-120-1280; or

(b) Health services rendered after the termination of the contract between the MCE and the provider, unless the health services were rendered during the confinement in an inpatient facility and the confinement began prior to the date of termination or unless the provider has assumed post-termination treatment obligations under the contract. Before providing a non-covered service, the provider must complete an OHP 3165, or facsimile, as described in OAR 410-120-1280.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3545 Temporary rule language in effect until 12/25/2026. CCO Behavioral Health Provider, Treatment and Facility Certification and Licensure

Behavioral health treatment services are covered for eligible OHP clients when provided by a CCO under the following circumstances:

(1) Provider Organizations, as defined under OAR 410-120-0000, that provide outpatient behavioral health services shall comply with all applicable federal and state rules, including but not limited to OAR chapter 309 and any requirements in the CCO contract, and meet the following criteria:

(a) Be certified by the Authority as described in OAR 309-008-0250 for the scope of services provided; or

(b) If located outside Oregon:

(A) Be licensed and in good standing in the state where the provider operates to provide the applicable services; and

(B) Be located no more than 75 miles from the Oregon border.

(2) A certificate may not be required for certain types of providers, regardless of whether public funds are received, as outlined in OAR 309-008-0250(4);

(3) Provider organizations (as defined under OAR 410-120-0000) of residential treatment services shall:

(a) Meet the definition of a residential treatment facility under ORS 430.010, 430.306 and 443.400;

(b) Be licensed by the Authority as described in ORS 443.725 and OAR chapter 415 divisions 12 and 50 for the scope of service provided; and

(c) Comply with applicable rules including, but not limited to, those defined in OAR chapter 415 and chapter 309 and any requirements in the CCO contract.

History

Statutory/Other Authority: ORS 413.042, 414.065, 430.010, 430.306, 443.400 & 443.725
Statutes/Other Implemented: ORS 413.042, 414.065, 430.010, 430.306 & 443.400
DMAP 26-2026, temporary amend filed 06/29/2026, effective 06/29/2026 through 12/25/2026
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3550 Resolving Disputes between MCEs and the Authority

(1) If an MCE has a dispute with the Authority as a result of a decision that is perceived as adversely affecting an MCE, the MCE may submit a request to the Director of the Authority, or the Director’s designee, requesting an Administrative Review, as prescribed in OAR 410-120-1580.

(a) These disputes primarily address legal or policy issues that may arise in the context of an Authority decision that is perceived by the MCE to adversely affect the MCE and is not otherwise reviewed as a claim redetermination, a contested case, or client appeal. An example of such disputes includes, but is not limited to, Authority decisions made through the OHA Provider Discrimination Review Process as a result of a provider discrimination appeal;

(b) This rule does not address claims that the Authority has breached its contract with an MCE;

(c) This MCE process is not mandatory, and it need not be exhausted before an MCE seeks judicial review or brings any other form of action related to any MCE/Authority dispute related decision.

(2) Within 30 calendar days of the conclusion of the administrative review, or such other time as may be agreed to by the MCE and the Authority, the Authority shall send written results of the administrative review to the initiating MCE and any other affected MCE. Should a resolution be reached through administrative review that is mutually agreeable to all involved, the process shall be considered complete and binding.

(3) If the dispute between the MCE and the Authority remains unresolved as a result of the administrative review, the CCO may request an alternative dispute resolution as set forth below to attempt to resolve the issue. The alternative dispute process is conducted pursuant to the Attorney General’s Uniform Model Rules OAR 137-005-0060 and 137-005-0070.

(4) Not more than 10 business days after receipt of the final administrative review decision, the MCE may contact the Director of the Authority indicating the MCE’s intent to pursue mediation. In that request, the MCE may request to stay the administrative review decision, which the Authority will grant if the MCE alleges sufficient facts and provides good cause for the stay as provided in OAR 137-004-0090. The Authority shall respond within 10 business days of the date of the stay request.

(5) After both the MCE and the Authority agree to enter into mediation, both shall attempt to agree on the selection of the mediator and complete paperwork required to secure the mediator’s services. If the MCE and the Authority are unable to agree on the selection of a mediator, both shall appoint a mediator, and those mediators shall select the final mediator. To be qualified to propose resolutions for disputes under this rule, the mediator shall:

(a) Be a knowledgeable and experienced mediator;

(b) Be familiar with health care and the disputed matters; and

(6) If the dispute is likely to impact another MCE, the Authority shall notify all MCEs potentially impacted by the dispute and provide an opportunity for the impacted MCEs to participate in the dispute resolution process. MCEs that opt into the process have, from that time forward, the same rights and responsibilities as the MCE that initiated the dispute.

(7) The MCE and the Authority shall share in the cost of all mediation expenses, whether the dispute is resolved or not.

(8) Within 10 business days of a selection of a mediator or upon a different schedule, as agreed to by the parties and the mediator, the MCE and the Authority shall submit to each other and to the mediator the following:

(a) Dispute resolution offer; and

(b) Explanation of their position, i.e., advocacy brief.

(9) The parties will engage in mediation as arranged by the mediator.

(10) The Authority shall maintain the confidentiality of proprietary information of all participating MCEs to the extent the information is protected under state or federal law.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042, ORS 183.484 & 183.502
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3555 Resolving Disputes between Health Care Entities and CCOs that Concern CCO Contact Award

(1) The dispute resolution process described in this rule applies only when, under ORS 414.635:

(a) An entity is applying to the Authority for contract award as a CCO (applicant);

(b) A Health Care Entity (HCE) and the applicant (together, the “parties” for purposes of this rule) have failed to agree upon terms for a contract; and

(A) The applicant states that the HCE is necessary for the applicant to qualify as a CCO;

(B) An HCE states that its inclusion is necessary for the applicant to be awarded a CCO; or

(C) In reviewing the applicant’s information, the Authority identifies the HCE as necessary for the applicant to qualify as a CCO.

(2) If an applicant and HCE disagree about whether the HCE is necessary for the successful award of a contract to the applicant as a CCO, the applicant or HCE may request the Authority to review the issue.

(3) If the Authority determines the HCE is not necessary for the applicant’s award of a contract, the process described in this rule does not apply.

(4) If the Authority determines or the parties agree the HCE is necessary for the applicant’s award of a contract, the following applies:

(a) The HCE and the applicant shall participate in good faith contract negotiations. The parties shall take the following actions in an attempt to reach a good faith resolution:

(A) The applicant shall provide a written offer of terms and conditions to the HCE. The HCE shall explain the area of disagreement to the applicant;

(B) The applicant’s or HCE’s chief financial officer, chief executive officer, or an individual authorized to make decisions on behalf of the HCE or applicant shall have at least one face-to-face meeting in a good faith effort to resolve the disagreement.

(b) The applicant or HCE may request the Authority to provide technical assistance. The Authority also may offer technical assistance, with or without a request. The Authority’s technical assistance is limited to clarifying the CCO contracting process, criteria, and other program requirements.

(5) Pursuant to ORS 414.635, if the applicant and HCE cannot reach agreement on contract terms within 10 calendar days of the face-to-face meeting, either party may request arbitration. The requesting party shall notify the other party in writing to initiate a referral to an independent third-party arbitrator for an HCE’s refusal to contract with the CCO or the termination, extension, or renewal of a HCE’s contract with a CCO. The party initiating the referral shall provide a copy of the notification to the Authority.

(6) After notification that one party-initiated arbitration, the parties shall attempt to agree upon the selection of the arbitrator and complete the paperwork required to secure the arbitrator’s services. If the parties are unable to agree, each party shall appoint an arbitrator, and these arbitrators shall select the final arbitrator.

(7) The parties shall pay for all arbitration costs. In consideration of potentially varied financial resources between the parties, which may pose a barrier to the use of this process, the parties may ask the arbitrator to allocate costs between the parties based on ability to pay.

(8) Within 10 calendar days of a referral to an arbitrator, the applicant and HCE shall submit to each other and to the arbitrator the following:

(a) The most reasonable contract offers; or

(b) The HCE’s statement that a contract is not desirable and an explanation of why this is reasonable.

(9) Within 10 calendar days of receiving the other party’s offer or the HCE’s statement that a contract is not desirable, each party shall submit to the arbitrator and the other party the advocacy briefs regarding whether the HCE is reasonably or unreasonably refusing to contract with the applicant.

(10) The arbitrator shall apply the following standards when making a determination about whether an HCE reasonably or unreasonably refused to contract with the applicant:

(a) An HCE may reasonably refuse to contract when an applicant’s reimbursement to an HCE for a health service is below the reasonable cost to provide the service. The arbitrator shall apply federal or state statutes or regulations that establish specific reimbursements, such as payments to federally qualified health centers, rural health centers, and tribal health centers; and

(b) An HCE may reasonably refuse to contract if that refusal is justified in fact or by circumstances, taking into consideration the health system transformation legislative policies. Facts or circumstances outlining what is a reasonable or unreasonable refusal to contract include, but are not limited to:

(A) Whether contracting with the applicant would impose demands that the HCE cannot reasonably meet without significant negative impact on HCE costs, obligations, or structure while considering the proposed reimbursement arrangement or other CCO requirements. Some of the requirements include:

(i) Use of electronic health records;

(ii) Service delivery requirements, or

(iii) Quality or performance requirements.

(B) Whether the HCE’s refusal affects access to covered services in the applicant’s community. This factor alone cannot result in a finding that the refusal to contract is unreasonable; however, the HCE and applicant shall make a good faith effort to work out differences in order to achieve beneficial community objectives and health system transformation policy objectives;

(C) Whether the HCE has entered into a binding obligation to participate in the network of a different CCO or applicant and that participation significantly reduces the HCE’s capacity to contract with the applicant.

(11) The following outlines the arbitrator determination and the parties’ final opportunity to settle:

(a) The arbitrator shall evaluate the final offers or statement of refusal to contract and the advocacy briefs from each party and issue a determination within 15 calendar days of the receipt of the parties’ information;

(b) The arbitrator shall provide the determination to the parties. The arbitrator and the parties may not disclose the determination to the Authority for 10 calendar days to allow the parties an opportunity to resolve the issue themselves. If the parties resolve the issue no later than the end of the tenth day, the arbitrator may not release the determination to the Authority;

(c) If the parties have not reached an agreement after 10 calendar days, the arbitrator shall provide its decision to the Authority. After submission to the Authority, the arbitrator’s determination becomes a public record, subject to protection of trade secret information if identified by one of the parties prior to the arbitrator’s submission of the determination.

(12) If the parties cannot agree, the Authority shall evaluate the arbitrator’s determination and may take the following actions:

(a) The Authority may award a contract to an applicant if the arbitrator determined the applicant made a reasonable attempt to contract with the HCE or the HCE’s refusal to contract was unreasonable;

(b) The Authority may refuse to award a contract to an applicant when the arbitrator determined the applicant did not reasonably attempt to contract with the HCE or the HCE’s refusal to contract was reasonable, and the Authority determines that participation from the HCE remains necessary for applicant’s award of a contract as a CCO;

(c) The Authority may not pay fee-for-service reimbursements to an HCE if the arbitrator determined the HCE unreasonably refused to contract with the applicant. This applies to health services available through a CCO;

(d) In any circumstance within the scope of this rule when the parties have failed to agree, the current statutes regarding reimbursement to non-participating providers shall apply to CCOs that hold contracts with OHA and the HCE, consistent with ORS 414.743 for hospitals and consistent with Authority rules for other providers.

(13) To be qualified to resolve disputes under this rule, the arbitrator shall:

(a) Be a knowledgeable and experienced arbitrator;

(b) Be familiar with health care provider contracting matters;

(d) Follow the terms and conditions specified in this rule for the arbitration process.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 78-2022, minor correction filed 09/30/2022, effective 09/30/2022
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
DMAP 30-2019, temporary adopt filed 08/07/2019, effective 08/07/2019 through 02/02/2020

Or. Admin. R. 410-141-3560 Resolving Contract Disputes Between Health Care Entities and CCOs

(1) Pursuant to ORS 414.635, Coordinated Care Organizations (CCOs) and Health Care Entities (HCEs) shall participate in good faith contract negotiations. This rule covers the termination, extension, and renewal of an HCE’s contract with a CCO.

(2) In the event of a dispute involving the termination, extension, or renewal of an HCE’s contract with a CCO, the parties may take the following actions in an attempt to reach a good faith resolution:

(a) Both parties shall provide a written offer of terms and conditions to the other party. The parties shall explain the basis for their disagreement with the terms and conditions offered by the other party;

(b) The CCO’s and HCE’s chief financial officer, chief executive officer, or an individual authorized to make decisions on behalf of the HCE or CCO shall have at least one face-to-face meeting in a good faith effort to resolve the disagreement;

(c) The CCO or HCE may request the Authority to provide technical assistance. The Authority’s technical assistance is limited to clarifying the CCO contractual provisions, subcontracting criteria, current reimbursement requirements, access standards, and other legal requirements.

(3) If the CCO and HCE cannot reach agreement on contract terms, the parties may engage in mediation. Either the CCO or the HCE may request mediation:

(a) After the parties have agreed to enter into mediation, the parties shall attempt to agree on the selection of the mediator and complete paperwork required to secure the mediator’s services. If the parties are unable to agree, each party shall appoint a mediator, and those mediators shall select the final mediator;

(b) To be qualified to propose resolutions for disputes under this rule, the mediator shall:

(A) Be a knowledgeable and experienced mediator;

(B) Be familiar with health care and contracting matters; and

(c) The parties shall pay for all mediation costs, whether a conclusion is reached or not. In consideration of potentially varied financial resources between the parties, which may pose a barrier to the use of this process, the parties may ask the mediator to allocate costs between the parties based on the ability to pay;

(d) Within 10 business days of a selection of a mediator, the CCO and HCE shall submit to each other and to the mediator the following:

(A) Contract offer; and

(B) Explanation of their position (i.e., advocacy brief).

(e) Unless an extension is agreed on by all parties, the mediator shall issue a report to the involved parties that will include mediation findings and recommendations no longer than 15 business days from the conclusion of the mediation.

(4) Pursuant to ORS 414.635, if the CCO and HCE cannot reach an agreement on contract terms within ten business days of receipt of the mediator’s report, either party may request non-binding arbitration. The requesting party shall notify the other party in writing of the party’s intent to refer the matter to arbitration:

(a) After notification that one party-initiated arbitration, the parties shall agree on the selection of the arbitrator and complete the paperwork required to secure the arbitrator’s services. If the parties are unable to agree, each party shall appoint an arbitrator, and these arbitrators shall select the final arbitrator;

(b) To be qualified to propose resolutions for disputes under this rule, the arbitrator shall:

(A) Be a knowledgeable and experienced arbitrator;

(B) Be familiar with health care provider contracting matters; and

(c) The parties shall pay for all arbitration costs. In consideration of potentially varied financial resources between the parties, which may pose a barrier to the use of this process, the parties may ask the arbitrator to allocate costs between the parties based on ability to pay;

(d) Within 10 business days of a selection of an arbitrator, the CCO and HCE shall submit to each other and to the arbitrator the following:

(A) Final contract offers; and

(B) Explanation of their position (i.e., advocacy brief).

(e) The arbitrator shall evaluate the final offers and the advocacy briefs from each party and issue a non-binding determination within 15 business days of the receipt of the parties’ submissions.

History

Statutory/Other Authority: ORS 413.042, ORS 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3565 Managed Care Entity Billing

(1) Providers shall submit all claims for MCE members in the following timeframes:

(a) Submit initial claims within no more than 120 days of the date of service for all cases, except as provided for in section (1)(b) of this rule. MCEs may negotiate terms within this timeframe agreeable to both parties;

(b) Submit initial claims within 365 days of the date of service in the following cases:

(A) Pregnancy;

(B) Eligibility issues such as retroactive deletions or retroactive enrollments;

(D) Other cases that delay the initial claim to the MCE, not including failure of the provider to verify the member's eligibility; or

(E) Third Party Liability (TPL). Pursuant to 42 CFR 136.61, subpart G: Indian Health Services and the amended Public Law 93-638 under the Memorandum of Agreement that Indian Health Service and 638 Tribal Facilities are the payers of last resort and are not considered an alternative liability or TPL.

(c) For initial claims submitted timely that need correction, have prompted a provider appeal as outlined in OAR 410-120-1560, or for a reason not included in (1)(b) of this rule that otherwise require a re-submission, MCEs shall establish a time-frame in their policies and procedures which allow a billing provider to make such re-submissions or appeals for a minimum of 180 days after the initial adjudication date.

(2) Providers shall be enrolled with the Authority to be eligible for fee-for-service (FFS) payments. Mental health providers, except Federally Qualified Health Centers (FQHC), shall be approved by the Local Mental Health Authority (LMHA) and the Authority before enrollment with the Authority or to be eligible for MCE payment for services. FFS providers may be retroactively enrolled in accordance with OAR 410-120-1260 Provider Enrollment.

(3) Providers, including mental health providers, shall be enrolled with the Authority as a Medicaid FFS provider or an MCE encounter-only provider prior to submission of encounter claims to ensure the encounter claim is accepted.

(4) Providers shall verify before providing services that the client is:

(a) Eligible for Authority programs and;

(b) Assigned to an MCE on the date of service.

(5) Providers shall use the Authority’s and MCE’s tools to determine if the service to be provided is covered under the member’s OHP benefit package. Providers shall also identify the party responsible for covering the intended service and seek Prior Authorizations from the appropriate payer before providing services. Before providing a non-covered service, the provider shall complete an OHP 3165 “OHP Client Agreement to Pay for Health Services”, or OHP “3166 OHP Client Agreement to Pay for Pharmacy Services” or facsimile signed by the client as described in OAR 410-120-1280.

(6) If a member has other insurance coverage available for payment of covered services, the insurance must be exhausted prior to payment for the covered services. Member cost-sharing incurred as part of other coverage shall be paid to the insurer by the MCE.

(7) MCEs shall pay for all covered services. These services shall be billed directly to the MCE, unless the MCE or the Authority specifies otherwise. No contracting provider or agent, trustee or assignee of the contracting provider shall bill a member, send a member’s bill to a Collection Agency, or maintain a civil action against a member to collect any amounts owed by the CCO for which the member is not liable to the contracting provider in this rule and under OAR 410-120-1280:

(a) A client may not be billed for missed appointments. A missed appointment is not considered to be a distinct Medicaid service by the federal government and as such is not billable to the client or the Division;

(b) A client may not be billed for services or treatments that have been denied due to provider error (e.g., required documentation not submitted, Prior Authorization not obtained, etc.).

(8) Payment by the MCE to participating providers for capitated or coordinated care services is a matter between the MCE and the participating provider:

(a) MCEs shall have written policies and procedures for processing claims submitted from any source. The policies and procedures shall specify timeframes for:

(A) Date stamping claims when received;

(B) Determining within a specific number of days from receipt whether a claim is valid or non-valid;

(D) Sending written notice of the decision with appeal rights to the member when the determination is a denial, in whole or in part, of payment for a service rendered as outlined in OAR 410-141-3875 and 410-141-3885.

(b) MCEs shall pay or deny at least 90 percent of valid claims within 30 days of receipt and at least 99 percent of valid claims within 90 days of receipt. MCEs shall make an initial determination on 99 percent of all claims submitted within 60 days of receipt;

(c) MCEs shall provide written notification of MCE determinations when the determinations result in a denial of payment for services as outlined in OAR 410-141-3885;

(d) MCEs may not require providers to delay claims submission to the MCE;

(e) MCEs may not require Medicare be billed as the primary insurer for services or items not covered by Medicare or require non-Medicare approved providers to bill Medicare;

(f) MCEs may not deny payment of valid claims when the potential TPR is based only on a diagnosis, and no potential TPR has been documented in the member's clinical record;

(g) MCEs may not delay or deny payments because a co-payment was not collected at the time of service;

(h) School-based Health Services (SBHS) must not apply toward a member’s health services allowances limited by an MCE’s utilization management policy. These services are supplemental to other health plan covered therapy services and are not considered duplicative services. This includes, but is not limited to, occupational therapy, physical therapy, speech and language therapy, cognitive rehabilitation, and dental services when a child is receiving such services as SBHS through an Individualized Education Program (IEP), an Individualized Family Service Plan (IFSP), a Section 504 Accommodation Plan, or any other individualized plan of care established for services provided by education agencies in support of the child or young adult’s education;

(i) MCEs may not deny a claim for behavioral health services on the basis that such services were delivered in the member’s home unless the MCE would deny a claim for comparable physical health services performed at the same site of service.

(9) MCEs shall pay for Medicare coinsurances and deductibles consistent with Oregon’s State Plan methodology up to the Medicare or MCE’s allowable for all Medicare Part A and Part B covered services the member receives from a Medicare enrolled provider after adjudication with Medicare or a Medicare Advantage plan:

(a) Providers must be enrolled in Oregon Medicaid to receive cost-sharing payments and non-enrolled providers should be given information on how to enroll to receive cost-sharing. Pursuant to OAR 410-120-1280, FFS Medicare providers should be encouraged to submit the Medicaid information necessary to enable electronic crossover to the MCE with their Medicare claims;

(b) MCEs and affiliated Medicare Advantage plan shall provide a process for automatic Medicare to Medicaid crossover payments to ensure cost-sharing and reduce duplicate provider submission of claims;

(c) Federal law bars Medicare providers and suppliers from billing an individual enrolled in the Qualified Medicare Beneficiary (QMB) program for Medicare Part A and Part B cost-sharing under any circumstances (see Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act [the Act]). The QMB program is a State Medicaid benefit that assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost-sharing, including deductibles, coinsurance, and copays;

(d) MCEs must inform providers of rules that prohibit balance billing and ensure providers serving and accepting plan payment for Qualified Medicare Beneficiaries that members cannot be balance-billed per Sections 1902(n)(3)(C) and 1905(p)(3) of the Social Security Act.

(10) MCEs shall pay transportation, meals, and lodging costs for the member and any required attendant for services that the MCE has arranged and authorized when those services are not available within the state, unless otherwise approved by the Authority.

(11) MCEs shall pay for ancillary covered services provided by a non-participating provider under the following conditions:

(a) MCEs shall pay for ancillary covered services provided by a non-participating provider that are not prior authorized if all of the following conditions exist:

(A) It can be verified that a participating provider ordered or directed the covered services to be delivered by a non-participating provider;

(B) The ancillary covered service was delivered in good faith without the Prior Authorization;

(C) The ancillary covered service would have been prior authorized with a participating provider if the MCE’s referral procedures had been followed.

(b) The MCE shall pay non-participating providers (providers enrolled with the Authority that do not have a contract with the MCE) for ancillary covered services that are subject to reimbursement from the MCE in the amount specified in OAR 410-120-1295. This rule does not apply to providers that are Type A or Type B hospitals, as they are paid in accordance with OAR 410-141-3565 (12-14);

(c) Except as specified in OAR 410-141-3840 Emergency and Urgent Care Services, MCEs shall not be required to pay for covered treatment services provided by a non-participating provider, unless:

(A) The MCE does not have a participating provider that will meet the member’s medical need; and

(B) The MCE has authorized care to a non-participating provider.

(d) Notwithstanding OAR 410-120-1280, non-participating providers may not attempt to bill the member for services rendered;

(e) MCEs shall reimburse hospitals for services provided on or after January 1, 2012, using Medicare Severity DRG for inpatient services and Ambulatory Payment Classification (APC) for outpatient services or other alternative payment methods that incorporate the most recent Medicare payment methodologies for both inpatient and outpatient services established by CMS for hospital services and alternative payment methodologies including but not limited to pay-for-performance, bundled payments, and capitation. An alternative payment methodology does not include reimbursement payment based on percentage of billed charges. This requirement does not apply to Type A or Type B hospitals. MCEs shall attest annually to the Authority in a manner to be prescribed to MCE’s compliance with these requirements. MCEs shall pay hospitals any applicable Qualified Directed Payments pursuant to OAR 410-125-0230.

(12) For Type A or Type B hospitals transitioning from Cost-Based Reimbursement (CBR) to an Alternative Payment Methodology (APM):

(a) Sections (12) and (14) only apply to services provided by Type A or Type B hospitals to members that are enrolled in an MCE;

(b) The Authority may upon evaluation by an actuary retained by the Authority, on a case-by-case basis, require MCEs to continue to reimburse fully a rural Type A or Type B hospital determined to be at financial risk for the cost of covered services based on a cost-to-charge ratio;

(c) For those Type A or Type B hospitals that transitioned from CBR to an APM, the Authority shall require hospitals and MCEs to enter into good faith negotiations for contracts. Dispute resolution during the contracting process shall be subject to OAR 410-141-3555 and 410-141-3560;

(d) For monitoring purposes, MCEs shall submit to the Authority no later than November 30 of each year a list of those hospitals with which they have contracted for these purposes.

(13) Determination of which Type A or Type B hospitals shall stay on CBR or transition from CBR:

(a) No later than June 30 of the odd numbered years, the Authority shall update the algorithm for calculation of the CBR determination methodology with the most recent data available;

(b) After determination for each Type A and Type B hospital, any changes in a hospital’s status from CBR to APM or from APM to CBR shall be effective January 1 of the following (even numbered) year;

(c) Type A and Type B hospitals located in a county that is designated as “Frontier” are not subject to determination via the algorithm and shall remain on CBR.

(14) Non-contracted Type A or Type B hospital rates for those transitioning or transitioned from CBR:

(a) Reimbursement rates under this section shall be based on discounted hospital charges for both inpatient and outpatient services;

(b) Reimbursement rates effective for the initial year of a hospital transitioning from CBR shall be based on that hospital’s most recently filed Medicare cost report adjusted to reflect the hospital’s OHP mix of services;

(c) Subsequent year reimbursement rates for hospitals transitioned from CBR shall be calculated by the Authority based on the individual hospital’s annual price increase and the Authority’s global budget rate increase as defined by the CMS 1115 waiver using the following formula: Current Reimbursement Rate x (1+Global Budget Increase) / (1+Hospital Price Increase);

(d) On an annual basis, each Type A or Type B hospital that has transitioned from CBR shall complete a template provided by the Authority that calculates the hospital’s change in prices for their MCE population;

(e) Inpatient and outpatient reimbursement rates shall be calculated separately;

(f) Non-contracted Type A or Type B hospital reimbursement rates can be found in the Rate Table on the Authority’s website.

(15) Members may receive certain services on a Fee-for-Service (FFS) basis:

(a) Certain services shall be authorized by the MCE or the Community Mental Health Program (CMHP) for some mental health services, even though the services are then paid by the Authority on a FFS basis. Before providing services, providers shall verify a member’s eligibility and MCE assignment as provided for in this rule;

(b) Services authorized by the MCE or CMHP are subject to the Authority’s administrative rules and supplemental information including rates and billing instructions;

(c) Providers shall bill the Authority directly for FFS services in accordance with billing instructions contained in the Authority administrative rules and supplemental information;

(d) The Authority shall pay at the Medicaid FFS rate in effect on the date the service is provided subject to the Authority’s administrative rules, contracts, and billing instructions;

(e) The Authority may not pay a provider for providing services for which an MCE has received an MCE payment unless otherwise provided for in rule;

(f) When an item or service is included in the rate paid to a medical institution, a residential facility, or foster home, provision of that item or service is not the responsibility of the Authority or an MCE except as provided in Authority administrative rules and supplemental information (e.g., coordinated care and capitated services that are not included in the nursing facility all-inclusive rate);

(g) MCEs that contract with FQHCs and RHCs shall negotiate a rate of reimbursement that is not less than the level and amount of payment that the MCE would pay for the same service furnished by a provider who is not an FQHC nor RHC, consistent with the requirements of Section 4712(b)(2) of the Balanced Budget Act of 1997.

(16) MCEs shall maintain a Coordination of Benefits Agreement that allows participation in the automated claims crossover process with Medicare for those members dually eligible for Medicaid and Medicare services.

(17) MCEs shall ensure providers under the MCE contract are notified of billing processes for crossover claims processing, as described in OAR 410-120-1280.

(18) Coverage of services through the OHP benefit package of covered services is limited by OAR 410-141-3825 Excluded Services and Limitations for OHP Clients.

(19) MCEs shall engage in collaborative efforts with the Authority to achieve the requirements of the CCO Value-based Purchasing Roadmap.

History

Statutory/Other Authority: ORS 413.042, 414.065, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.065 & 414.610 - 414.685
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 62-2022, temporary amend filed 06/26/2022, effective 06/30/2022 through 12/26/2022
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3570 Managed Care Entity Encounter Claims Data Reporting

(1) MCEs shall meet the data content and submission standards as required by HIPAA 45 CFR Part 162, the Authority's electronic data transaction rules (OAR 943-120-0100 through 943-120-0200), the Authority's 837 technical specifications for encounter data, and the Authority's encounter data submission guidelines that are subject to periodic revisions and available on the Authority's website.

(2) MCEs shall collect service information in standardized formats to the extent feasible and appropriate; if HIPAA standard, the MCE must utilize the HIPAA standards:

(a) MCEs shall submit encounter claims for all covered services provided to members as defined in OAR 410-120-0000 and 410-141-3500;

(b) MCEs shall submit encounter claims data including encounters for:

(A) Services where the MCE determined that liability exists, even if the MCE did not make any payment for a claim;

(B) Services where the MCE determined that no liability exists;

(C) Services to members provided by a provider under a subcontract, capitation, or special arrangement with another facility or program;

(D) Paid amounts regardless of whether the servicing provider is paid on a fee-for-service (FFS) basis, on a capitated basis by the MCE, or the MCE's subcontractor; and

(E) Services to members who also have Medicare coverage, if a claim has been submitted to the MCE.

(c) MCEs shall obtain a Coordination of Benefits Agreement (COBA) number and coordinate with COBA to receive direct crossover claims for dually eligible members with traditional Medicare pursuant to 42 CFR 438.3(t);

(d) MCEs shall report encounter claims data whether the provider is an in-network participating or out-of-network, non-participating provider.

(3) MCEs shall follow the DCBS standards for electronic data exchange as described in the Oregon Companion Guides available on the DCBS website.

(4) MCEs shall submit all valid unduplicated encounter claims for professional, dental, institutional, and pharmacy within 45 days of the date of adjudication:

(a) MCEs shall ensure all pharmacy encounter claims data meet the data content standards as required by the National Council for Prescription Drug Programs (NCPDP) as available on their website or by contacting the National Council for Prescription Drug Programs organization;

(b) Submission Standards and Data Availability:

(A) MCEs shall only use the two types of provider identifiers, as allowed by HIPAA NPI standards 45 CFR 160.103 and as provided to the MCE by the Authority in encounter claims:

(i) The National Provider Identifiers (NPI) for a provider covered entity enrolled with the Authority; or

(ii) The Oregon Medicaid proprietary provider numbers for the Authority enrolled non-covered atypical provider entities.

(B) MCEs shall make an adjustment to any encounter claim within 30 days of discovering the data is incorrect, no longer valid, or some element of the claim not identified as part of the original claim needs to be changed;

(C) If the Authority discovers errors or a conflict with a previously adjudicated encounter claim except as specified in paragraph (E) of this section, the MCE must adjust or void the encounter claim within 30 days of notification by the Authority of the required action or as identified in paragraph (E) of this section;

(D) If the Authority discovers errors with a previously adjudicated encounter claim resulting from a federal or state mandate or request that requires the completeness and accuracy of the encounter data, the MCE must correct the errors within a timeframe specified by the Authority;

(E) If circumstances prevent the MCE from meeting requested timeframes for correction, the MCE may contact the Authority to determine an agreed upon specified date;

(F) MCEs retain liability for certifying encounter data as complete, truthful, and accurate. MCEs must ensure claims data received from providers, either directly or through a third-party submitter, is accurate, truthful, and complete by:

(i) Verifying accuracy and timeliness of reported data;

(ii) Screening data for completeness, logic, and consistency;

(iii) Submitting a complete and accurate Encounter Data Certification and Validation Report available on the Authority's website.

(G) MCEs shall make all collected and reported data available upon request to the Authority and CMS as described in 42 CFR 438.242.

(A) The Authority shall notify the MCE of the status of all encounter claims processed;

(B) Notification of all encounter claims processed that are in a “must correct” status shall be provided by the Authority to the MCE each week and for each subsequent week the encounter claim remains in a “must correct” status;

(C) The Authority may notify the MCE of other errors; however, this information is also available in the MCE's electronic remittance advice supplied by the Authority;

(D) MCEs shall submit corrections to all encounter claims within 63 days from the date the Authority sends the MCE notice that the encounter claim remains in a “must correct” status;

(E) MCEs Shall not delete encounter claims with a “must correct” status as specified in section (3)(d), except when the Authority has determined the encounter claim cannot be corrected or for other reasons.

(5) Electronic Health Records (EHR) Systems OAR 410-165-0000 to 410-165-0140. In support of an eligible provider's ability to demonstrate meaningful use as an EHR user, as described by 42 CFR 495.4 and 42 CFR 495.8, the MCE must:

(a) Submit encounter data in support of a qualified EHR user's meaningful use data report to the Authority for validation as set forth in OAR 410-165-0080;

(b) Respond within the timeframe determined by the Authority to any request for:

(A) Any suspected missing MCE encounter claims, or;

(B) MCE-submitted encounter claims found to be unmatched to an EHR user's meaningful use report.

(6) MCEs shall comply with the following hysterectomy and sterilization standards as described in 42 CFR 441.250 to 441.259 and the requirements of OAR 410-130-0580:

(a) MCEs shall submit a signed informed consent form to the Authority for each member that received either a hysterectomy or sterilization service within 30 days of claims adjudication as defined in OAR 410-141-3500; or immediately upon notification by the Authority that a qualifying encounter claim has been identified;

(b) The Authority in collaboration and cooperation with the MCE shall reconcile all hysterectomy or sterilization services with informed consents with the associated encounter claims by either:

(A) Confirming the validity of the consent and notifying the MCE that no further action is needed;

(B) Requesting a corrected informed consent form; or

(C) Informing the MCE, the informed consent is missing or invalid and the payment must be recouped, and the associated encounter claim must be changed to reflect no payment made for services within the timeframe set by the Authority.

(7) Upon request by the Authority, MCEs shall furnish information regarding rebates for any covered outpatient drug provided by the MCE as follows:

(a) The Authority is eligible for the rebates authorized under Section 1927 of the Social Security Act (42 USC 1396r-8) as amended by section 2501 of the Patient Protection and Affordable Care Act (P.L. 111-148) and section 1206 of the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) for any covered outpatient drug provided by the MCE, unless the drug is subject to discounts under Section 340B of the Public Health Service Act;

(b) MCEs shall report prescription drug data as specified in section (3)(b) of this rule.

(8) Encounter Pharmacy Data Rebate Dispute Resolution as governed by SSA Section 1927 42 U.S.C. 1396r-8 and as required by OAR 410-121-0000 through 410-121-0625. When the Authority receives an Invoiced Rebate Dispute from a drug manufacturer, the Authority shall send the Invoiced Rebate Dispute to the MCE for review and resolution within 15 days of receipt:

(a) The MCE shall assist in the dispute process as follows:

(A) By notifying the Authority that the MCE agrees an error has been made; and

(B) By correcting and re-submitting the pharmacy encounter data to the Authority within 45 days of receipt of the Invoiced Rebate Dispute.

(b) If the MCE disagrees with the Invoiced Rebate Dispute that an error has been made, the MCE shall send the details of the disagreement to the Authority's encounter data liaison within 45 days of receipt of the Invoiced Rebate Dispute.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3575 MCE Member Relations: Marketing

(1) The following definitions apply for purposes of OAR 410-141-3575 through 410-141-3585:

(a) “Alternate Format” means any alternate approach to presenting print information to an individual with a disability. This term includes, at a minimum, the types of alternate formats defined under the Americans with Disabilities Act (ADA) and 45 CFR Part 92, and shall include: braille, large (18 point) print, audio narration, oral presentation, electronic file, sign language interpretation, and sighted guide;

(b) “Cold-call Marketing” means any unsolicited personal contact with a potential member for the purpose of marketing by the MCE;

(c) “Marketing” means any communication from an MCE to a potential member who is not enrolled in the MCE that can reasonably be interpreted as intended to compel or entice the potential member to enroll in that particular MCE;

(d) “Marketing Materials” means materials that are produced in any medium by or on behalf of an MCE and that can reasonably be interpreted as intended to market to potential members;

(e) “Outreach” means any communication from an MCE to any audience that cannot reasonably be interpreted as intended to compel or entice a potential member to enroll in a particular MCE. Outreach activities include, but are not limited to, the act of raising the awareness of the CCO, the MCE’s subcontractors and partners, and the MCE contractually required programs and services; and the promotion of healthful behaviors, health education and health related events. For full benefit dual eligible (FBDE) members, outreach to provide information about opportunity to align Medicare and Medicaid benefits, or CMS approved Default or Simplified enrollment for newly Medicare eligible member in the CCO regarding MA or DSNP, is allowable subject to OHA or CMS materials review.

(f) “Outreach Materials” means materials that are produced in any medium, by or on behalf of an MCE that cannot reasonably be interpreted as intended to compel or entice a potential member to enroll in a particular MCE;

(g) “Potential Member” means, as defined in OAR 410-141-3500, a person who meets the eligibility requirements to enroll in the Oregon Health Plan but has not yet enrolled with a specific MCE;

(h) “Prevalent Non-English Language” means all non-English languages that are identified during the eligibility process as the preferred written language by the lesser of:

(A) Five percent of the MCE’s total OHP enrollment; or

(B) One thousand of the MCE’s members;

(i) “Readily Accessible” has the meaning provided for in OAR 410-141-3500.

(j) “Written Member Materials” means informational and educational communications for members or potential members that are produced by or on behalf of an MCE in any written medium, including but not limited to: letters, brochures, guides, scripts, email, and text messaging. All written member materials must comply with the Authority’s formatting and readability standards, as described in OAR 410-141-3585 and 42 CFR § 438.10, and be written in plain language sufficiently clear that a layperson could understand the information.

(2) MCEs shall comply with 42 CFR §§ 438.10, 438.100 and 438.104 to ensure that before enrolling OHP clients, the MCE provides accurate oral and written information that potential members need to make an informed decision on whether to enroll in that MCE. MCEs shall distribute the materials to its entire service area as indicated in its MCE contract. The MCEs may not:

(a) Distribute any marketing materials without first obtaining state approval;

(b) Seek to compel or entice enrollment in conjunction with the sale of or offering of any private insurance; and

(3) The following outreach to members or potential members are expressly permitted:

(a) The creation of name recognition by an MCE. Permissible methods for creating name recognition include, but are not limited to, brochures, pamphlets, newsletters, posters, fliers, websites, bus wraps, billboards, web banners, health fairs, or health-related events;

(b) An MCE or its subcontractor’s communications that express participation in or support for an MCE by its founding organizations or its subcontractors, so long as the communications do not constitute an attempt to compel or entice a client’s enrollment;

(c) The following communications related to full benefit dual-eligible (FBDE) members with affiliated or contracted MA or DSNP plans, and member’s Medicare and Medicaid providers, as long as they do not constitute an attempt by the MCE to influence client enrollment:

(A) Communications to notify full benefit dual-eligible (FBDE) members of opportunities to align MCE-provided benefits with Medicare Advantage or Special Needs Plans or access ICC services;

(i) Provision of information about CCO’s affiliated Medicare Advantage Plan or Dual Special Needs Plan, contact information to inquire about the plan or provider network, and opt-in enrollment form;

(ii) Provision of aligned Medicare Advantage or Dual Special Needs Plan Simplified or Default enrollment letters, and CMS approved communication materials for newly eligible members.

(B) Improving coordination of care through mechanisms such as referral to LTSS assessment with ODHS or providers of Home and Community Based Services, interdisciplinary care conferences, and use of HIE and event notifications;

(C) Communicating with providers serving full benefit dual-eligible (FBDE) members about unique care coordination needs or member needs such as ICC services, service authorizations, goals to ensure preventive screenings and assessments are scheduled as recommended, auxiliary aids and services or interpreter services; or

(D) Streamlining communications to the full benefit dual eligible (FBDE) member to improve coordination of benefits including provision of integrated member materials, i.e. handbooks, provider directories, summary of Medicare-Medicaid benefits, and ID cards for members with aligned MA or DSNP and CCO enrollment.

(4) MCEs shall update plan access information with the Authority on a monthly basis for use in updating the Authority’s availability charts. The Authority shall confirm information before posting availability charts.

(5) MCEs and when applicable, the aligned Medicare Advantage or Dual Special Needs Plan have sole accountability for producing or distributing materials following Authority approval.

(6) MCEs shall comply with the Authority’s marketing materials guidelines or other requirements for the submission, approval, review and correction of marketing materials or other communications with members or potential members. MCEs shall participate, as required, in development of guidelines or other requirements with the Authority through a transparent public process, including stakeholder input. The guidelines include, but are not limited to:

(a) A list of communication or outreach materials subject to review by the Authority;

(b) A clear explanation of the Authority’s process for review and approval of marketing materials;

(d) An update of plan availability information submitted to the Authority on a monthly basis for review and posting.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 3-2023, minor correction filed 02/01/2023, effective 02/01/2023
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3580 MCE Member Relations: Potential Member Information

(1) In addition to the requirements below, information for potential members shall comply with the marketing requirements and prohibitions in 42 CFR § 438.104 and OAR 410-141-3575 and any requirements or guidelines adopted by the Authority there under.

(2) MCEs shall develop informational materials for potential members and provide such materials to the Authority. An MCE or the Authority may include informational materials in the application packet for potential members.

(3) MCEs’ informational materials shall be sufficient for the potential member to make an informed decision about provider selection.

(4) The MCE shall make available to potential members, upon request, information on participating providers. MCE provider directories for potential members shall include all specified elements and be made readily accessible as defined in 42 CFR 438.10.

(5) MCEs’ informational materials shall include the following information for potential members regarding the rights of American Indians and Alaskan Natives:

(a) MCEs’ informational materials shall state that American Indians and Alaskan Natives enrolled in the MCEs may select an Indian health care provider (IHCP) that is participating as a primary care provider within the network of the MCE, insofar as the individual is otherwise eligible to receive primary care services from such IHCP and the IHCP has the capacity to provide primary care services to such American Indians and Alaskan Natives.

(b) MCEs shall clearly explain to potential members that American Indians and Alaskan Natives enrolled in an MCE shall also be permitted to obtain primary care services covered under the contract between the state and MCE from out-of-network IHCPs from whom the enrollee is otherwise eligible to receive primary care services. American Indians and Alaskan Natives may be referred by out-of-network IHCPs to a network provider without prior authorization or referral from a participating provider.

(6) MCEs’ informational materials for potential members in their service area shall meet the following language requirements:

(a) Materials shall be culturally and linguistically appropriate and be sensitive to people with disabilities or reading limitations, including those whose primary language is not English;

(b) MCEs shall accommodate requests made by potential members, potential members’ family members, or potential members’ caregivers for language accommodation, translating to the potential member’s language needs as requested. Alternate formats shall be provided and may include but are not limited to braille, large (18 point) print, audio narration, oral presentation, and electronic file along with other aids and services for other disabilities, including sign language interpretation and sighted guide.

(c) MCEs shall address health literacy issues by preparing informational materials at a 6th grade reading level, incorporating graphics and utilizing alternate format materials for potential members and using a minimum 12-point font or large print (18 point). MCEs shall make written informational materials available in alternative formats upon request of the potential member at no cost. Auxiliary aids and services and interpreter services must also be made available upon request of the potential member at no cost.

(7) MCEs shall ensure that all staff who have contact with potential members are:

(a) Fully informed of MCE and Authority rules applicable to enrollment, disenrollment, complaint and grievance policies and procedures, the availability of free qualified or certified health care interpreters in any language required by the member including American Sign Language, and the process for requesting auxiliary aids or alternative format materials;

(b) Able to assist members in determining which participating providers:

(A) Have capacity in languages other than English;

(B) Have offices/facilities that are accessible and have accommodations for people with physical disabilities, including but not limited to offices, exam rooms, restrooms and equipment; and

(c) Trained in cultural competency and trauma-informed care, as those terms are defined in OAR 309-035-0105 and in accordance with CCO Health Equity Plan Training and Education plan described in 410-141-3735.

(8) MCE staff shall be able to provide potential members with information on how to access the Authority Beneficiary Support System, including information for full benefit dual-eligible (FBDE) members on how to receive choice counseling on Medicaid and Medicare options as required in 42 CFR 438.71.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3585 CCO Member Relations: Education and Information

(1) CCOs may engage in activities for existing members related to outreach, health promotion, and health education. The CCO must obtain approval of the Authority prior to distribution of any written communication by the CCO or its subcontractors and providers that:

(a) Is intended solely for members; and

(b) Pertains to requirements for obtaining coordinated care services at service area sites or benefits.

(2) CCOs may communicate with providers, caseworkers, community agencies, and other interested parties for informational purposes or to enable care coordination and address social determinants of health or community health. The intent of these communications should be informational only for building community linkages to impact social determinants of health or member care coordination and not to entice or solicit membership. Communication methodologies may include but are not limited to brochures, pamphlets, newsletters, posters, fliers, websites, health fairs, or sponsorship of health-related events. CCOs shall address health literacy issues by preparing these documents at a low literacy reading level, incorporating graphics and utilizing alternate formats.

(3) CCOs shall have a mechanism to help members understand the requirements and benefits of the CCO’s coordinated care model. The mechanisms developed shall be culturally and linguistically appropriate. Written materials, including provider directories, member handbooks, appeal and grievance notices, and all denial and termination notices are made available in the prevalent non-English languages as defined in OAR 410-141-3575 in its particular service area and be available in formats noted in section (5) of this rule for members with disabilities. CCOs shall accommodate requests made by other sources such as members, family members, or caregivers for language accommodation, translating to the member’s language needs as requested.

(4) CCOs shall have written procedures, criteria, and an ongoing process of member education and information sharing that includes member orientation, member handbook, and health education. CCOs shall update their educational material as they add coordinated services. Member education shall:

(a) Be made available in the prevalent non-English languages in the CCOs service area and provided in alternate formats upon request and free of charge in compliance with 42 CFR 438.10. Auxiliary aids and services must also be made available upon request at no cost;

(b) Include information about the care coordination approach and how to navigate the coordinated health care system and where applicable for Full Benefit Dual Eligible (FBDE) members, the process for coordinating Medicaid and Medicare benefits;

(c) Clearly explain how members may receive assistance from certified and qualified health care interpreters and Traditional Health Workers as defined in OAR 950-060-0010;

(d) Inform all members of the availability of Ombudsperson services.

(5) Written member materials shall comply with the following language and access requirements:

(a) Materials shall be translated in the prevalent non-English languages as defined in OAR 410-141-3575 in the service area as well as include taglines in large print (font size 18) explaining the availability of written translation or oral interpretation to understand the information provided, as well as alternate formats, and the toll-free and TTY/TDY telephone number of the CCO’s member/customer service unit;

(b) Materials shall be made available in alternative formats upon request of the member at no cost. Auxiliary aids and services must also be made available upon request of the member at no cost. The CCO’s process for providing alternative formats and auxiliary aids to members must not in effect deny or limit access to covered services, grievance, appeals, or hearings;

(c) Electronic versions of member materials shall be made available on the CCO website, including provider directories, formularies, and handbooks in a form that can be electronically retained and printed, available in a machine-readable file and format, is searchable and Readily Accessible. For any required member education materials on the CCO website, the member is informed that the information is available in paper form without charge upon request to Members and Member representatives, and the CCO shall provide it upon request within five business days.

(6) CCO provider directories shall be a single, comprehensive resource that encompasses the CCO’s entire Provider Network, including any Providers contracted by Subcontractors that serve the CCO’s Members. CCOs must not utilize a Subcontractor’s separate or standalone provider directory to meet the Provider Directory requirement and shall include:

(a) The provider’s name as well as any group affiliation;

(b) Street address(es);

(d) Website URL, as appropriate;

(e) Provider Specialty, as appropriate;

(f) National Provider Identifier (NPI), as appropriate;

(g) Whether the provider shall accept new members;

(h) Whether the provider offers both telehealth and in-person appointments;

(i) Information about the provider’s race and ethnicity, cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or an Authority-approved qualified and, as applicable, certified health care interpreter(s) at no cost to members at the provider’s office;

(j) Availability of auxiliary aids and services for all members with disabilities upon request and at no cost;

(k) Narrative space that is optional for providers to list biographical, cultural, linguistic, or other relevant information.

(l) Whether the provider’s office or facility is accessible and has accommodations for people with physical disabilities, including but not limited to information on specific accessibility features of provider’s offices, exam rooms, and equipment (e.g., wide entries, wheelchair access, accessible exam tables and rooms, lifts, scales, restrooms, grab bars, or other equipment).

(m) The information for each of the following provider types covered under the contract, as applicable to the CCO contract:

(A) Physicians, including specialists, available to members on an outpatient basis and not solely available in a nursing facility or other institutional setting;

(B) Hospitals;

(D) Behavioral health providers; including specifying substance use treatment providers;

(E) Dental providers;

(F) HRSN Service Providers.

(n) Information included in the provider directory shall be updated at least monthly, and electronic provider directories shall be updated no later than thirty (30) days after the CCO receives updated provider information. Updated materials shall be available on the CCO website in a readily accessible and machine-readable file per form upon request and another alternative format.

(7) Each CCO shall make available in electronic or paper form the following information about its formulary:

(a) Which medications are covered both generic and name brand;

(b) What tier each medication is on.

(8) Within fourteen (14) days of a CCO’s receiving notice of a member’s enrollment, CCOs shall mail a welcome packet to new members and to members returning to the CCO twelve (12) months or more after previous enrollment. The packet shall include, at a minimum, a welcome letter, an ID card, a Notice of Availability of Language Access, a Notice of Nondiscrimination, and information on how to access a member handbook and a provider directory, including a list of any in-network retail and mail-order pharmacies.

(9) For existing CCO members, a CCO shall notify members annually of the availability of a member handbook and provider directory and how to access those materials. CCOs shall send hard copies upon request within five days. CCOs must also notify members of their nondiscrimination policies annually and as otherwise specified in 45 CFR 92.10.

(10) CCOs must notify enrollees:

(a) That interpreter services in any language required by the member, including American Sign Language, auxiliary aids and alternative format materials are available free of charge to CCO members in its health programs and activities as stated in 42 CFR 438.10. This notice must be provided in the manner specified in 45 CFR 92.11;

(b) The process for requesting and accessing interpreters or auxiliary aids and alternative formats, including where appropriate how to contact specific providers responsible through sub-contracts to ensure provision of language and disability access;

(c) Language access services also applies to member representatives, family members and caregivers with hearing impairments or limited English proficiency who need to understand the member’s condition and care.

(11) A CCO shall electronically provide to the Authority for approval each version of the printed welcome packet that includes a welcome letter, an ID card, a Notice of Availability of Language Access, a Notice of Nondiscrimination, and information on how to access a member handbook and a provider directory.

(12) CCOs shall adopt the language in the Authority’s Model Member Handbook. CCO Member Handbooks shall comply with the Authority’s formatting and readability standards.

(13) Member health education shall include:

(a) Information on specific health care procedures, instruction in self-management of health care, promotion and maintenance of optimal health care status, patient self-care, and disease and accident prevention. CCO providers or other individuals or programs approved by the CCO may provide health education. CCOs shall make every effort to provide health education in a culturally sensitive and linguistically appropriate manner in order to communicate most effectively with individuals from non-dominant cultures;

(b) Information specifying that CCOs must not prohibit or otherwise restrict a provider acting within the lawful scope of practice from advising or advocating on behalf of a member who is their patient for the following:

(A) The member’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered;

(B) Any information the member needs to decide among all relevant treatment options;

(c) CCOs shall ensure development and maintenance of an individualized health educational plan for members whom their provider has identified as requiring specific educational intervention. The Authority may assist in developing materials that address specifically identified health education problems to the population in need;

(d) An explanation of care coordination and how members may participate in those services. CCOs shall ensure that care coordination related education is provided to members with special health care needs as defined in OAR 410-141-3500;

(e) The appropriate use of the delivery system, including proactive and effective education of members on how to access emergency services and urgent care services appropriately;

(f) CCOs shall provide written notice to affected members of any Material Changes to Delivery System as defined in OAR 410-141-3500 or any other significant changes in provider(s), program, or service sites that affect the member’s ability to access care or services from CCO’s participating providers. The CCO shall provide, translated as appropriate, the notice at least thirty (30) days before the effective date of that change, or within fifteen (15) calendar days after receipt or issuance of the termination notice if the participating provider has not given the CCO sufficient notification to meet the thirty (30) day notice requirement. The Authority shall review and approve the materials within two (2) working days.

(14) CCOs shall provide an identification card to members, unless waived by the Authority, that contains simple, readable, and usable information on how to access care in an urgent or emergency situation. The cards are solely for the convenience of the CCO, members, and providers.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 101-2025, temporary amend filed 12/30/2025, effective 01/02/2026 through 06/30/2026
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 99-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3590 MCE Member Relations: Member Rights and Responsibilities

(1) MCEs shall:

(a) Have written policies and procedures that ensure that members have the rights and responsibilities included in this rule;

(b) Communicate these policies and procedures to participating providers;

(c) Monitor compliance with these policies and procedures, take corrective action as needed, and report findings to the Quality Improvement Committee defined under OAR 410-141-3525.

(2) MCE members shall have the following rights and are entitled to:

(a) Be treated with dignity and respect;

(b) Be treated by participating providers the same as other people seeking health care benefits to which they are entitled and to be encouraged to work with the member’s care team, including providers and community resources appropriate to the member’s needs;

(c) Choose a Primary Care Provider (PCP) or service site and to change those choices as permitted in the MCE’s administrative policies;

(d) Refer oneself directly to behavioral health or family planning services without getting a referral from a PCP or other participating provider;

(e) Have a friend, family member, member representative, or advocate present during appointments and other times as needed within clinical guidelines;

(f) Be actively involved in the development of their treatment plan;

(g) Be given information about their condition and covered and non-covered services to allow an informed decision about proposed treatments;

(h) Consent to treatment or refuse services and be told the consequences of that decision, except for court ordered services;

(i) Receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency;

(j) Have written materials explained in a manner that is understandable to the member and be educated about the coordinated care approach being used in the community and how to navigate the coordinated health care system;

(k) Receive communications of individually identifiable health information from the MCE by alternative means or at alternative locations per 45 CFR 164.522 if the member provides a written statement that includes:

(A) A valid alternative address or other method of contact suitable for enabling the member to receive communications from the MCE (e.g., valid cell phone number, verifiable e-mail address); and

(B) If required by the MCE, a clearly stated disclosure that all or part of the protected health information could put the member in danger.

(L) Receive culturally and linguistically appropriate services and supports in locations as geographically close to where members reside or seek services as possible and choice of providers within the delivery system network that are, if available, offered in non-traditional settings that are accessible to families, diverse communities, and underserved populations;

(m) Receive oversight, care coordination and transition and planning management from their MCE within the targeted population to ensure culturally and linguistically appropriate community-based care is provided in a way that serves them in as natural and integrated an environment as possible and that minimizes the use of institutional care;

(n) Receive necessary and reasonable services to diagnose the presenting condition;

(o) Receive integrated person-centered care and services designed to provide choice, independence and dignity and that meet generally accepted standards of practice and are medically appropriate;

(p) Have a consistent and stable relationship with a care team that is responsible for comprehensive care management;

(q) Receive assistance in navigating the health care delivery system and in accessing community and social support services and statewide resources including but not limited to the use of certified or qualified health care interpreters, certified traditional health workers including community health workers, peer wellness specialists, peer support specialists, doulas, and personal health navigators who are part of the member’s care team to provide cultural and linguistic assistance appropriate to the member’s need to access appropriate services and participate in processes affecting the member’s care and services;

(r) Obtain covered preventive services;

(s) Have access to urgent and emergency services 24 hours a day, seven days a week without prior authorization;

(t) Receive a referral to specialty providers for medically appropriate covered coordinated care services in the manner provided in the MCE’s referral policy;

(u) Have a clinical record maintained that documents conditions, services received, and referrals made;

(v) Have access to one's own clinical record, unless restricted by statute;

(w) Transfer of a copy of the clinical record to another provider;

(x) Execute a statement of wishes for treatment, including the right to accept or refuse medical, surgical, or behavioral health treatment and the right to execute directives and powers of attorney for health care established under ORS 127;

(y) Receive written notices before a denial of, or change in, a benefit or service level is made, unless a notice is not required by federal or state regulations;

(z) Be able to make a complaint or appeal with the MCE and receive a response;

(aa) Request a contested case hearing;

(bb) Receive certified or qualified health care interpreter services; and

(cc) Receive a notice of an appointment cancellation in a timely manner;

(dd) Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in other federal regulations on the use of restraints and seclusion.

(3) CCO members shall have the following responsibilities:

(a) Choose or help with assignment to a PCP or service site;

(b) Treat the MCE, provider, and clinic staff members with respect;

(c) Be on time for appointments made with providers and to call in advance to cancel if unable to keep the appointment or if expected to be late;

(d) Seek periodic health exams and preventive services from the PCP or clinic;

(e) Use the PCP or clinic for diagnostic and other care except in an emergency;

(f) Obtain a referral to a specialist from the PCP or clinic before seeking care from a specialist unless self-referral to the specialist is allowed;

(g) Use urgent and emergency services appropriately and notify the member’s PCP or clinic within 72 hours of using emergency services in the manner provided in the MCE’s referral policy;

(h) Give accurate information for inclusion in the clinical record;

(i) Help the provider or clinic obtain clinical records from other providers that may include signing an authorization for release of information;

(j) Ask questions about conditions, treatments, and other issues related to care that is not understood;

(k) Use information provided by MCE providers or care teams to make informed decisions about treatment before it is given;

(L) Help in the creation of a treatment plan with the provider;

(m) Follow prescribed agreed upon treatment plans and actively engage in their health care;

(n) Tell the provider that the member’s health care is covered under the OHP before services are received and, if requested, show the provider the Division Medical Care Identification form;

(o) Tell the Department or Authority worker of a change of address or phone number;

(p) Tell the Department or Authority worker if the member becomes pregnant and notify the worker of the birth of the member's child;

(q) Tell the Department or Authority worker if any family members move in or out of the household;

(r) Tell the Department or Authority worker if there is any other insurance available;

(s) Pay for non-covered services under the provisions described in OAR 410-120-1200 and 410-120-1280;

(t) Pay the monthly OHP premium on time if so required;

(u) Assist the MCE in pursuing any third-party resources available and reimburse the MCE the amount of benefits it paid for an injury from any recovery received from that injury; and

(v) Bring issues or complaints or grievances to the attention of the MCE.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635, 414.651 & CFR 164.522
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3591 MCE Interoperability Requirements

(1) Interoperability and Access to Health Information

(a) MCEs shall comply with all federal regulations set forth in the CMS Interoperability and Patient Access Final Rule.

(b) All MCEs shall review the Office of National Coordinator for Health Information Technology (ONC) 21st Century Cures Act Final Rule relating to determine the applicably of the rule to their organizations’ s obligation to comply with the final rule. This includes the organization’s status as an Actor and the applicability of information blocking.

(2) For the purpose of this rule, the following definitions shall apply:

(a) “Application Programming Interface” (API) – means a technological interface defining the kinds of programming calls or requests that may be performed against an underlying data source;

(b) “Publicly Accessible’’ means that any person using commonly available technology to browse the internet could access the information without any preconditions or additional steps, such as:

(A) A fee for access to the documentation;

(B) A requirement to receive a copy of the material via email;

(D) A requirement to read promotional material or agree to receive future communications from the organization making the documentation available.

(c) “Third-Party Application” means a computer program that is developed and distributed by an organization or individual other than that which owns, administers, or manufactures the data being accessed;

(d) “Data Sharing Agreement” means a formal contract detailing what data are being shared and the appropriate use of those data;

(e) “Information blocking” means a practice by a health care provider, health IT developer, health information exchange, or health information network that, except as required by law or specified by the Secretary of Health & Human Services (HHS) as a reasonable and necessary activity, is likely to interfere with access, exchange, or use of electronic health information.

(3) MCEs must implement and maintain standards-based APIs that permits Third-Party Applications to retrieve data, with the approval and at the direction of the current individual member or the member’s personal representative through the use of common technologies, without special effort from the member or Data Sharing Agreement with the Third-Party Application. APIs must meet the following requirements:

(a) Interoperability requirements at 45 CFR 170.215 and technical requirements found at Federal Regulation § 422.119(c) including identity proofing and authentication processes that must be met by Third-Party Application developers in order to connect to the API and access the specific member’s data through the API;

(b) MCEs must comply with content and vocabulary standard requirements as applicable to the data type or data element found at 45 CFR 170.213 and 45 CFR part 162 and 42 CFR Part 406 § 423.160 unless alternate standards are required by other applicable law;

(c) For each API implemented, MCEs shall make publicly accessible, by posting directly on its website or via publicly accessible hyperlink(s), complete accompanying documentation that contains, at a minimum the following information:

(A) API syntax, function names, required and optional parameters supported and their data types, return variables and their types/structures, exceptions and exception handling methods and their returns;

(B) The software components and configurations that an application must use in order to successfully interact with the API and process its response(s); and

(C) All applicable technical requirements and attributes necessary for an application to be registered with any authorization server(s) deployed in conjunction with the API.

(4) MCEs must conduct routine monitoring and testing and update as appropriate to ensure the API functions properly, including assessments to verify that the API is fully and successfully implementing privacy and security features to ensure compliance with all state and federal laws to protect the privacy and security of individually identifiable data.

(5) MCEs shall deny or discontinue any third-party application’s connection to the API if it:

(a) Reasonably determines, consistent with its security risk analysis under 45 CFR part 164 subpart C, that allowing an application to connect or remain connected to the API would present an unacceptable level of risk to the security of protected health information on the MCE’s systems; and

(b) Makes this determination using objective, verifiable criteria that are applied fairly and consistently across all applications and developers through which members seek to access their electronic health information as defined at 45 CFR 171.102, including but not limited to criteria that may rely on automated monitoring and risk mitigation tools.

(6) MCEs must provide in a readily accessible manner on their public website and through other appropriate mechanisms through which it ordinarily communicates with current and former members seeking to access their health information held by the MCE, educational resources in non-technical, simple and easy-to-understand language explaining at a minimum:

(a) General information on steps the member may consider taking to help protect the privacy and security of their health information, including factors to consider in selecting an application including secondary uses of data, and the importance of understanding the security and privacy practices of any application to which they will entrust their health information; and

(b) An overview of which types of organizations or individuals are and are not likely to be HIPAA covered entities, the oversight responsibilities of the US Department of Health and Human Services, Office of Civil Rights (OCR) and the Federal Trade Commission (FTC), and how to submit a complaint to both agencies.

(7) MCEs must implement and maintain a standards-based API that permits third-party applications to retrieve, with the approval and at the direction of a member or the member’s personal representative, data specified in this section through the use of common technologies and without special effort from the member:

(a) Data concerning adjudicated claims, including claims data for payment decisions that may be appealed, were appealed, or are in the process of appeal, and provider remittances no later than one (1) business day after a claim is adjudicated;

(b) Data concerning adjudicated claims for prescription drug utilization including those carved out from MCE contracts, including remittances, no later than one (1) business day after a claim is adjudicated or carve-out utilization is reported to the MCE;

(c) All encounter data, including encounter data from any network providers the MCE is compensating on the basis of capitation payments, adjudicated claims and encounter data from any subcontractors must be available no later than one (1) business day after data concerning the encounter is received by the MCE;

(d) Clinical data, including laboratory results, if the MCE maintains any such data, no later than one (1) business day after the data is received by the MCE; and

(e) Formulary data that includes covered outpatient drugs, and any tiered formulary structure or utilization management procedure which pertains to those drugs.

(8) MCEs shall make provider directory information available publicly through a standards-based API. Information shall include provider names, addresses, phone numbers, and specialty. APIs shall be implemented consistent with Federal Regulation §422.119. Information shall be updated no later than 30 calendar days after the MCE receives provider directory information or updates to provider directory information.

(9) MCEs shall provide a process for the electronic exchange of, at a minimum, the data classes and elements included in the content standard adopted at 45 CFR 170.213 and identified in the United States Core Data for Interoperability (USCDI):

(a) Such information received by the MCE shall be incorporated into the MCE’s records about the current member;

(b) Upon approval and at the direction of a current or former member or their personal representative, the MCE shall:

(A) Receive all such data for a current member from any other payer obligated to provide it under federal regulations, that has provided coverage to the enrollee within the preceding 5 years;

(B) At any time the member is currently enrolled in the MCE and up to 5 years after disenrollment, send all such data to any other payer that currently covers the enrollee or a payer the enrollee or the enrollee’s personal representative specifically requests receive the data; and

(C) Send data received from another payer obligated to provide it under federal regulations, in the electronic form and format it was received.

(c) MCEs shall comply with the requirements of this section with regard to data they maintain with a date of service on or after January 1, 2016.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 28-2021, adopt filed 06/28/2021, effective 07/01/2021

Or. Admin. R. 410-141-3600 MCE Assessment: Definitions

The following definitions apply for purposes of OAR 410-141-3600 through 3655:

(1) "Deficiency" means the amount by which the assessment as correctly computed exceeds the assessment, if any, reported by the managed care entities (MCEs).

(2) "Delinquency" means the MCE failed to file a report when due or to pay the assessment as correctly computed when the assessment was due.

(3) “MCE Assessment” means the managed care assessment defined under OAR 410-141-3610.

(4) “Recoupment” means an accounts receivable system that collects money owed by the provider to the Authority by withholding all or a portion of a provider's future payments.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3601 MCE Assessment: General Administration

(1) The purpose of these rules is to govern the administration, enforcement, and collection of the managed care assessment on MCEs.

(2) MCEs shall pay an assessment on the gross amount of premium equivalents received during a calendar quarter:

(a) The MCE assessment rate for the period beginning January 1, 2018 and ending December 31, 2019, is 1.5 percent;

(b) The MCE assessment rate for the period beginning January 1, 2020 and ending December 31, 2026, is 2 percent.

(3) MCE assessments imposed are in addition to and not in lieu of any assessment, surcharge, or other assessment imposed on an MCE.

(4) The Authority may develop forms and reporting requirements and change the forms and reporting requirements as necessary to administer, enforce, and collect the assessments.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3605 MCE Assessment: Disclosure of Information

(1) Except as otherwise required by law, the Authority may not publicly divulge or disclose the amount of income, expense, or other particulars set forth or disclosed in any report or return required in the administration of the assessments. Particulars include but are not limited to social security numbers, employer numbers, or other organization identification numbers, and any business records required to be submitted to or inspected by the Authority to allow it to determine the amount of any assessments, delinquencies, or deficiencies payable or paid, or otherwise administer, enforce, or collect a health care assessment to the extent that the information would be exempt from disclosure under ORS 192.345(5).

(2) The Authority may:

(a) Upon request, furnish any MCE or its authorized representative with a copy of the MCE's report filed with the Authority for any quarter, or with a copy of any other information filed by the MCE in connection with the report, or as the Authority considers necessary;

(b) Publish information or statistics so classified as to prevent the identification of income or any particulars contained in any report or return; and

(c) Disclose and give access to an officer or employee of the Authority or its designee, or to the authorized representatives of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, the Controller General of the United States, the Oregon Secretary of State, the Oregon Department of Justice, the Oregon Department of Justice Medicaid Fraud Control Unit, and other employees of the state or federal government unless the Authority deems disclosure or access necessary or appropriate for the performance of official duties in the Authority’s administration, enforcement, or collection of these assessments.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3610 MCE Assessment: Calculation, Report, Due Date, Verification

(1) The MCE assessment on the premium equivalents paid to an MCE on or after January 1, 2018, is based on calendar quarters. Calendar quarter start dates are January 1, April 1, July 1, and October 1. For purposes of this rule, premium equivalents shall be assessed as of the calendar quarter in which the premium equivalents are received by the MCE.

(2) Premium equivalents include all capitation payments received by the MCE for the provision of health services and all other payments received by the MCE from the Authority for providing health services under ORS chapter 414, including maternity payments, quality incentive pool payments, and qualified directed payments as defined in OAR 410-125-0230. Premium equivalents do not include Medicare premiums or any form of payment by Oregon Health Plan (OHP) enrollees.

(3) Adjustments to premium equivalents subject to assessment shall be determined as follows:

(a) Premium equivalents attributable to periods prior to January 1, 2018, except annual quality incentive pool payments, are not subject to the assessment and shall be deducted from the assessable premium equivalents when calculating the assessment due;

(b) Adjustments due to changes in client status and other premium equivalents adjustments resulting in additional payments received by the MCE on or after April 1, 2018, are subject to the assessment;

(c) If premium equivalents are reduced by a recoupment by the Authority for an overpayment, then the assessable premium equivalents shall be the reduced amount after recoupment;

(d) If both an overpayment and recoupment occur, the MCE shall be subject to the assessment on the premium equivalents received in the calendar quarter; and

(e) Sub-capitation payments made to an MCE by another MCE are not included in the total premium equivalents subject to assessment if the paying MCE certifies to the receiving MCE in writing that the paying MCE is already responsible for the managed care assessment on the originating premium equivalents.

(4) The MCE must pay the MCE assessment and file the report on a form approved by the Authority on or before the 45th day following the end of the calendar quarter for which an assessment is due unless the Authority permits a later payment date. The MCE must provide all required information on the report.

(5) Any report, statement, or other document required to be filed shall be certified by the MCE’s chief financial officer or designee. The certification must attest, based on best knowledge, information, and belief to the accuracy, completeness, and truthfulness of the document.

(6) Payments may be made electronically or by paper check. If the MCE pays electronically, the accompanying report may either be faxed or mailed to the Authority. If the MCE pays by paper check, the accompanying report must be mailed with the check to the address provided on the report form.

(7) The Authority may charge the MCE a fee of $100 if for any reason the check, draft, order, or electronic funds transfer request is dishonored. This charge is in addition to any penalty for nonpayment of the assessments that may also be due.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3615 MCE Assessment: Filing an Amended Report

(1) The claims for refunds or payments of additional MCE assessment must be submitted by the MCE on an Authority approved form. The MCE must provide all information required on the report. The Authority may audit the MCE, request additional information, or request an informal conference prior to granting a refund or as part of its review of a payment of a deficiency.

(2) Claim for refund:

(a) If the amount of the MCE assessment imposed is less than the amount paid by the MCE and the MCE does not then owe an assessment for any other calendar period, the Authority may refund the overpayment. In no event shall a refund applicable to a particular calendar quarter exceed the assessment amount actually paid by the MCE;

(b) The MCE may file a claim for refund on an Authority approved form within 180 days after the end of the calendar quarter to which the claim for refund applies;

(c) If there is an amount due from the MCE to the Authority for any past due assessments or penalties, any refund otherwise allowable shall first be applied to the unpaid assessments and penalties, and the Authority shall notify the MCE.

(3) Payment of deficiency:

(a) If the amount of the MCE assessment is more than the amount paid by the MCE, the MCE may file a corrected report and pay the deficiency at any time. The penalty under OAR 410-141-3635 shall stop accruing after the Authority receives full payment of the total deficiency for the calendar quarter;

(b) If there is an error in the determination of the assessment due, the MCE may describe the circumstances of the late additional payment with the late filing of the amended report. The Authority, in its sole discretion, shall determine the penalty for such late additional payments pursuant to OAR 410-141-3635.

(4) If the Authority discovers or identifies information that it determines could give rise to the issuance of a notice of proposed action or the issuance of a refund, the Authority shall issue notification pursuant to OAR 410-141-3640.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: 2017 HB 2391
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3620 MCE Assessment: Determining the Date Filed

(1) For the purposes of these rules, any reports, requests, appeals, payments, or other response by the MCE must be either:

(a) Received by the Authority before the close of business on the date due; or

(b) If mailed, postmarked before midnight of the due date.

(2) When the due date falls on a Saturday, Sunday, or legal holiday, the response is due on the next business day.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3625 MCE Assessment: Authority to Audit Records

(1) The MCE must maintain financial records necessary and adequate to determine the amount of premium equivalents for any period for which an MCE assessment may be due.

(2) The Authority may audit the MCE's records at any time for a period of five years following the date the assessment is due to verify or determine the premium equivalents for the MCE.

(3) Any audit, finding, or position may be reopened if there is evidence of fraud, malfeasance, concealment, misrepresentation of material fact, omission of income, or collusion either by the MCE or by the MCE and an Authority representative.

(4) The Authority may notify the MCE of a potential deficiency or issue a refund based upon its audit findings.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3630 MCE Assessment: Determining Assessment Liability on Failure to File

(1) In the case of a failure by the MCE to file a report or to maintain necessary and adequate records, the Authority shall determine the MCE assessment liability according to the best of its information and belief.

(2) Best of its information and belief means the Authority shall use evidence available to the Authority at the time of the determination on which a reasonable person would rely on to determine the assessment.

(3) The Authority's determination of assessment liability shall be the basis for the assessment due in any notice of proposed action.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3635 MCE Assessment: Financial Penalty for Failure to File a Report or Failure to Pay Assessment When Due

(1) An MCE that fails to file a report or pay an MCE assessment in full when due is subject to a penalty of up to $500 per day of delinquency. The penalty accrues from the date of delinquency, notwithstanding the date of any notice under these rules.

(2) The total amount of penalty imposed under this section for each reporting period may not exceed five percent of the assessment for the reporting period for which the penalty is being imposed.

(3) In determining the amount of the penalty, the Authority shall consider evidence, such as:

(a) The MCE’s history of prior late payments and prior penalties;

(b) The MCE’s actions to come into compliance;

(c) The occurrence of unforeseeable circumstances against which it would have been unreasonable for the MCE to take precautions and which the MCE cannot avoid even by using its best efforts. Such circumstances include, but are not limited to, a natural disaster (e.g., earthquakes, floods, tornadoes), fires, an act of war (e.g., hostilities, invasion, terrorism, civil disorder), or other circumstances not within the reasonable control of the MCE;

(d) In the case of a deficiency due to an error when the MCE files a timely original return and pays the assessment identified in the return, the nature and extent of the error, evidence of prior errors, and the MCE’s explanation of the circumstances related to the error.

(4) The Authority shall collect any penalties imposed under this section and deposit the funds in the Health System Fund.

(5) Penalties paid under this section are in addition to the MCE assessment.

(6) If the Authority determines that an MCE is subject to a penalty under this section, the Authority shall issue a notice of proposed action as described in OAR 410-141-3640.

(7) If an MCE requests a contested case hearing, the Director of the Authority, at the Director's sole discretion, may reduce the amount of penalty assessed.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3640 MCE Assessment: Notice of Proposed Action

(1) Prior to issuing a notice of proposed action, the Authority shall notify the MCE of a potential deficiency or failure to report that could give rise to the imposition of a penalty. The Authority shall issue a 30-day notification letter within 30 calendar days of the report or payment due date. The MCE shall have 30 calendar days from the date of the notice to respond. The Authority may consider the response, if any, and any amended report under OAR 410-141-3615 in its notice of proposed action. In all cases that the Authority has determined that an MCE has an MCE assessment deficiency or failure to report, the Authority shall issue a notice of proposed action. The Authority may not issue a notice of proposed action if the issue is resolved satisfactorily within 59 days from the date of mailing the 30-day notification letter.

(2) The Authority shall issue a notice of proposed action within 60 calendar days from the date of mailing the 30-day notification letter.

(3) Contents of the notice of proposed action must include:

(a) The applicable calendar quarter;

(b) The basis for determining the corrected amount of assessment for the quarter;

(d) The amount of assessment paid for the quarter by the MCE;

(e) The resulting deficiency, which is the difference between the amount received by the Authority for the calendar quarter and the corrected amount due as determined by the Authority;

(f) Statutory basis for the penalty;

(g) Amount of penalty per day of delinquency;

(h) Date upon which the penalty began to accrue;

(i) Date the penalty stopped accruing or circumstances under which the penalty will stop accruing;

(j) The total penalty accrued up to the date of the notice;

(k) Instructions for responding to the notice; and

(L) A statement of the MCE's right to a hearing.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3645 MCE Assessment: Hearing Process

(1) Any MCE that receives a notice of proposed action may request a contested case hearing pursuant to ORS 183.411 through 183.500.

(2) The MCE may request a hearing by submitting a written request within 20 days of the date of the notice of proposed action.

(3) Prior to the hearing, the MCE shall meet with the Authority for an informal conference:

(a) The informal conference may be used to negotiate a written settlement agreement;

(b) If the settlement agreement includes a reduction or waiver of penalties, the agreement must be approved and signed by the Director of the Authority.

(4) Except as provided in section (5) of this rule, if the case proceeds to a hearing, the administrative law judge shall issue a proposed order with respect to the notice of proposed action. The Authority shall issue a final order.

(5) Nothing in this section shall preclude the Authority and the MCE from agreeing to informal disposition of the contested case at any time.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3650 MCE Assessment: Final Order of Payment

The Authority shall issue a final order of payment for deficiencies or penalties when:

(1) The MCE did not make a timely request for a hearing;

(2) Any part of the deficiency or penalty was upheld after a hearing;

(3) Upon agreement of the MCE and the Authority.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3655 Assessment: Remedies Available after Final Order of Payment

(1) Collection activities including but not limited to deducting the amount of the final deficiency or penalty from any sum then or later owed to the MCE by the Authority;

(2) Every payment obligation shall bear interest at the statutory rate of interest in ORS 82.010 accruing from the date of the final order of payment and continuing until the payment obligation, including interest, has been discharged.

History

Statutory/Other Authority: ORS 413.042 & 414.025
Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3700 CCO Application and Contracting Procedures

(1) The Authority shall establish an application process for entities seeking contracts as CCOs, in conformity with this OAR 410-141-3700 and OAR 410-141-3705. The following definitions apply with respect to that application process:

(a) “Applicant” means the entity submitting an application to be a CCO, or to enter into or amend a contract for coordinated care services;

(b) “Application” means an applicant’s written response to a Request for Applications;

(c) “Request for Applications (RFA)” means the document used for soliciting applications for a CCO, award of or amendment of a CCO services contract, or other objectives as the Authority may determine appropriate for procuring coordinated care services.

(2) The Authority shall use the following RFA processes for CCO procurement and contracting:

(a) The Authority shall provide public notice of every RFA on its website in a readily accessible manner. The RFA shall indicate how prospective applicants are made aware of addenda by posting notice of the RFA on the electronic system for notification to the public of Authority procurement opportunities or, upon request, by mailing notice of the availability of the RFA to persons that have expressed interest in the RFA;

(b) The RFA process shall begin with a public notice that shall be communicated using the OregonBuys website, or a successor website utilized by the state. A public notice of an RFA shall identify the services the Authority is seeking, the designated service areas where services are requested, sample contracts, and how potential applicants can keep informed of RFA updates;

(c) The RFA may specify that applicants must submit a letter of intent to the Authority within the specified time period. The letter of intent does not commit any applicant to apply. If a letter of intent is required, the Authority may not consider applications from applicants who fail to submit a timely letter of intent except as provided in the RFA;

(d) The RFA may request applicants to appear at a public meeting to provide information about the application;

(e) The RFA shall include, at a minimum, the elements required under OAR 410-141-3705, and shall request information from applicants to allow the Authority to engage in appropriate state supervision necessary to promote state action immunity under state and federal antitrust laws;

(f) The Authority shall consider only applications that are responsive, completed as described in the RFA, and submitted in the time and manner described in the RFA. The RFA may require electronic submission of the application in accordance with OAR 137-047-0330, Electronic Procurements. If an electronic procurement process is used, applications shall be accepted only from applicants who accept the terms and conditions of the electronic method being used for application submission.

(3) Readiness Reviews:

(a) The Authority shall have discretion whether to have a readiness review process unless otherwise required by law and require successful completion of the readiness review as a condition to contracting;

(b) If the Authority chooses to have a readiness review process and require successful completion as a condition to contracting, the process shall be described in the underlying procurement document or otherwise communicated to respondents during the procurement process;

(c) Readiness review shall include those areas required by law and may also include other topics identified by the Authority;

(d) The Authority reserves the right to request to provide updated information gleaned during the readiness review process throughout the term of the resulting contract(s) as needed for compliance monitoring and performance reviews.

(4) The Authority shall determine that organizations meet the criteria for being CCOs as follows:

(a) The Authority shall issue CCO contracts only to applicants that meet the criteria in OAR 410-141-3705, meet the RFA requirements, and provide the assurances specified in the RFA. The Authority shall determine if the applicant qualifies for being a CCO based on the application and any additional information and investigation that the Authority may require;

(b) The Authority shall notify each applicant that applies for CCO status if it meets the criteria for being a CCO;

(A) For members and potential members, optimize access to care and choice of providers, and where possible choice among CCOs;

(B) For providers, optimize choice in contracting with CCOs; and

(C) Allow more than one CCO to serve the geographic area if desirable to optimize access and choice under this subsection.

(d) The Authority may determine that an applicant is potentially eligible for a CCO contract in accordance with paragraph (f) below. The Authority is not obligated to determine whether an applicant is potentially eligible for a CCO contract if, in its discretion, the Authority determines that sufficient applicants eligible for a CCO contract are available to attain the Authority’s objectives under the RFA;

(e) The Authority may determine that an applicant is potentially eligible for a CCO contract if:

(A) The Authority finds that the applicant is reasonably capable of meeting the operational and solvency requirements of the RFA within a specified period; and

(B) The applicant enters into discussions with the Authority about areas of qualification that must be met before the applicant is operationally and financially eligible for a CCO contract. The Authority shall determine the date and required documentation and written assurances required from the applicant;

(C) If the Authority determines that an applicant potentially eligible for a CCO contract does not meet the criteria for a CCO contract within the time announced in the RFA for contract award, the Authority may:

(i) Offer a CCO contract at a future date to a potentially eligible CCO that the Authority identified during the same period it made the determination for all other applicants (as described in subsections (a) – (c) and (f) of this section (4) of this rule) to a specific RFA. The offer of a CCO contract at a future date that is permitted under this rule shall be subject to the potentially eligible CCO applicant demonstrating to the Authority’s satisfaction that the applicant is eligible for a CCO contract within the scope of and subject to the requirements of the RFA; or

(ii) Inform the applicant that it is not eligible for a CCO contract.

(f) The Authority shall enter into a new contract(s) or contract renewal with a CCO only if the CCO meets the criteria for being a CCO and the Authority determines that the contract(s) would be within the scope of the RFA and consistent with the purposes and effective administration of the Oregon Integrated and Coordinated Health Care Delivery System that includes but is not limited to:

(A) The capacity of any existing CCO in the region compared to the capacity of an additional CCO for the number of potential enrollees in the addenda; and

(B) The number of CCOs in the region.

(5) The application is the applicant’s offer to enter into a contract(s) and is a firm offer for the period specified in the RFA. The Authority’s award of the contract(s) constitutes acceptance of the offer and binds the applicant to the contract:

(a) Except to the extent the applicant is authorized to propose certain terms and conditions pursuant to the RFA, an applicant may not make its offer contingent on the Authority’s acceptance of any terms or conditions other than those contained in the RFA;

(b) The Authority may enter into negotiation with applicants concerning potential capacity and enrollment in relation to other available or potentially available capacity, the number of potential enrollees within the service area, and other factors identified in the RFA;

(c) The Authority may award multiple contracts or make a single award or limited number of awards to meet the Authority’s needs, including but not limited to adequate capacity for the potential enrollees in the service area, maximizing the availability of coordinated care services, and achieving the objectives in the RFA; and

(d) Subject to any limitations in the RFA, the Authority may execute a contract renewal for CCO services by amending an existing contract or issuing a replacement contract without issuing a new RFA.

(6) Disclosure of application contents and release of information:

(a) Except for the letter of intent to apply, information may not be disclosed to any applicant or the public until the award date, unless otherwise specified in the RFA and allowed by law. The “award date” refers to the date on which the Authority acts on the applications by issuing or denying certification and by awarding or not awarding contracts. No information may be given to any applicant or the public relative to its standing with other applicants before the award date except under the following circumstances:

(A) The information in the application may be shared with the Authority, DCBS, Oregon Health Insurance Marketplace, PEBB, OEBB, PERS, CMS, and those individuals involved in the application review and evaluation process; and

(B) Information may be provided by the applicant to the public as part of a public review process.

(b) Application information may be disclosed on the award date, except for information that has been clearly identified and labeled confidential in the manner specified in the RFA if the Authority determines it meets the disclosure exemption requirements.

(7) The Authority shall interpret and apply this rule to satisfy federal procurement and contracting requirements in addition to state requirements applicable to contracts with CCOs. The Authority must seek and receive federal approval of CCO contracts funded by federal funds.

(8) Except where inconsistent with the preceding sections of this rule, the Authority adopts the following Department of Justice (DOJ) Model Public Contract Rules (as in effect on June 30, 2018) to govern RFAs and contracting with CCOs:

(a) General Provisions Related to Public Contracting: OARs 137-046-0100, 137-046-0110, and 137-046-0400 through 137-046-0480;

(b) Public Procurements for Goods or Services: OARs 137-047-0100, 137-047-0260 through 137-047-0670, 137-047-700 to 137-047-0760 (excluding provisions governing judicial review), and 137-047-0800;

(A) An application is a proposal under the DOJ Model Rules;

(B) An RFA is an RFP under the DOJ Model Rules;

(C) Certification as a CCO is pre-qualification under the DOJ Model Rules if the Authority requires certification as a condition to contract;

(D) Provisions of the Public Contracting Code referenced in the DOJ Model Rules are incorporated herein;

(E) Definitions in the DOJ Model Rules govern this rule except where a term is defined in section (1) of this rule.

(9) Judicial review of the Authority’s decisions relating to a solicitation protest, certification, or contract award is governed by the Oregon Administrative Procedures Act (APA). The RFA may establish when an Authority decision may be considered a final order for purposes of APA review.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3705 Criteria for CCOs

(1) In administering the procurement process described in OAR 410-141-3700, the Authority shall require applicants to describe their capacity and plans for meeting the goals and requirements established for the Oregon Integrated and Coordinated Health Care Delivery System, including being prepared to enroll all eligible individuals within the CCO’s proposed service area. The Authority shall develop an RFA that includes, at a minimum, the elements described in this rule:

(a) This rule lists legal requirements for CCOs, followed by corresponding application requirements that CCO applicants shall be required to address in the RFA;

(b) The Authority shall interpret the qualifications and expectations for CCO contracting within the context of the laws establishing health system transformation, as well as the Oregon Health Policy Board’s adopted reports and policies;

(A) The Authority recognizes that CCOs and partner organizations need time to develop capacity, relationships, systems, and experience to fully realize the goals envisioned by the Oregon Integrated and Coordinated Health Care Delivery System;

(B) An applicant who does not yet satisfy an RFA criterion must, at a minimum, have plans in place to meet the criterion. Unless otherwise specified in law or in the RFA, the Authority may use discretion in assessing whether the applicant is likely to make sufficient progress in implementing those plans to merit selection as a CCO candidate. Depending on the applicant’s level of readiness, the Authority may consider invoking its authority under OAR 410-141-3700(4)(f) to deem an applicant “potentially eligible;”

(C) Contract provisions, including an approved Transformation and Quality Strategy (TQS) and work plan for implementing health services transformation, shall describe how the CCO will comply with transformation requirements under these rules throughout the term of the CCO contract to maintain compliance.

(2) Applicants shall describe their demonstrated experience and capacity for:

(a) Managing financial risk and establishing financial reserves;

(b) Meeting the following minimum financial requirements:

(A) Maintaining restricted reserves of $250,000 plus an amount equal to 50 percent of the entity’s total actual or projected liabilities above $250,000;

(B) Maintaining a net worth in an amount equal to at least five percent of the average combined revenue in the prior two quarters of the participating health care entities.

(d) Developing and implementing alternative payment methodologies that are based on health care quality and improved health outcomes;

(e) Coordinating the delivery of physical health care, mental health and Substance Use Disorder (SUD) services, dental services , and covered long-term care services;

(f) Engaging community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic, and racial disparities in health care that exist among the entity’s enrollees and in the entity’s community.

(3) Each CCO shall have a governance structure that meets the requirements of ORS 414.572. The applicant shall:

(a) Clearly describe how it meets governance structure criteria from ORS 414.572, how the governance structure makeup reflects community needs and supports the goals of health care transformation, how the criteria are used to select governance structure members, and how it assures transparency in governance;

(b) Identify key leaders who are responsible for successful implementation and sustainable operation of the CCO;

(c) Describe how its governance structure reflects the needs of members with serious and persistent mental illnesses and members receiving Medicaid-funded long-term care, services, and supports.

(4) Each CCO shall convene a community advisory council (CAC) that meets the requirements of ORS 414.572. The applicant shall clearly describe how it meets the requirements for selection and implementation of a CAC consistent with ORS 414.572, how the CAC is administered to achieve the goals of community involvement, and the development, adoption, and updating of the community health assessment and community health improvement plan.

(5) CCOs shall partner with their local public health authority, hospital system, type B AAA, APD field office, and local mental health authority to develop a shared community health assessment that includes a focus on health disparities in the community:

(a) Since community health assessments evolve over time as relationships develop and CCOs learn what information is most useful, initial CCO applicants may not have time to conduct a comprehensive community assessment before operating as a CCO;

(b) The applicant shall describe how it develops its health assessment, meaningfully and systematically engaging representatives of critical populations and community stakeholders and its community advisory council to create a health improvement plan for addressing community needs that builds on community resources and skills and emphasizes innovation.

(6) The CCO shall describe its strategy to adopt and implement a community health improvement plan consistent with OAR 410-141-3730.

(7) CCOs shall have agreements in place with publicly funded providers to allow payment for point-of-contact services including immunizations, sexually transmitted diseases and other communicable diseases, family planning, and HIV/AIDS prevention services. Applicants shall confirm that these agreements have been developed unless good cause can be shown:

(a) CCOs shall also have agreements in place with the local mental health authority consistent with ORS 414.153. Applicants shall confirm that these agreements have been developed unless good cause can be shown;

(b) The Authority shall review CCO applications to ensure that statutory requirements regarding county agreements are met unless good cause is shown why an agreement is not feasible.

(8) CCOs shall provide integrated, person‐centered care and services designed to provide choice, independence, and dignity. The applicant shall describe its strategy:

(a) To assure that each member receives integrated, person‐centered care and services designed to provide choice, independence, and dignity;

(b) For providing members the right care at the right place and the right time and to integrate and coordinate care across the delivery system.

(9) CCOs shall develop mechanisms to monitor and protect against underutilization of services and inappropriate denials, provide access to certified advocates, and promote education and engagement to help members be active partners in their own care. Applicants shall describe:

(a) Planned or established policies and procedures that protect member rights including access to qualified peer wellness specialists, peer-delivered services specialists, personal health navigators, and qualified community health workers where appropriate;

(b) Planned or established mechanisms for a complaint, grievance, and appeals resolution process, including how that process shall be communicated to members and providers.

(10) CCOs shall operate in a manner that encourages patient engagement, activation, and accountability for the member’s own health. Applicants shall describe how they plan to:

(a) Actively engage members in the design and, where applicable, implementation of their treatment and care plans;

(b) Ensure that member choices are reflected in the development of treatment plans, and member dignity is respected.

(11) CCOs shall assure that members have a choice of providers within the CCO’s network, including providers of culturally and linguistically appropriate services and their providers participating in the CCO and shall:

(a) Work together to develop best practices for care and service delivery to reduce waste and improve health and well‐being of all members;

(b) Be educated about the integrated approach and how to access and communicate within the integrated system about a member’s treatment plan and health history;

(c) Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making, and communication;

(d) Be permitted to participate in the networks of multiple CCOs;

(e) Include providers of specialty care;

(f) Be selected by the CCO using universal application and credentialing procedures, objective quality information, and are removed if the providers fail to meet objective quality standards;

(g) Establish and demonstrate compliance with 42 CFR part 438, subpart K regarding parity in mental health and substance use disorder benefits in alignment with contractual requirements;

(h) Describe how they will work with their providers to develop the partnerships necessary to allow for access to and coordination with medical, mental health and mobile crisis services, Substance Use Disorder (SUD) service providers, and dental services, and facilitate access to community social and support services including Medicaid-funded LTCSS, mental health crisis services, and culturally and linguistically appropriate services;

(i) Describe their planned or established tools for provider use to assist in the education of members about care coordination and the responsibilities of both parties in the process of communication.

(12) CCOs shall assure that each member has a consistent and stable relationship with a care team that is responsible for providing preventive and primary care and for comprehensive care management in all settings. The applicant shall demonstrate how it will support the flow of information, identify a lead provider or care team to confer with all providers responsible for a member’s care, and use a standardized patient follow-up approach.

(13) CCOs shall address the supportive and therapeutic needs of each member in a holistic fashion using patient‐centered primary care homes and individualized care:

(a) Applicants shall describe their model of care or other models that support patient-centered primary care, adhere to ORS 414.572 requirements regarding individualized care plans particularly for members with intensive care coordination needs, and screen for all other issues including mental health;

(b) Applicants shall describe how its implementation of individualized care plans reflects member or family and caregiver preferences and goals to ensure engagement and satisfaction.

(14) CCOs shall assure that members receive comprehensive transitional health care including appropriate follow‐up care when entering or leaving an acute care facility or long-term care setting to include warm handoffs as appropriate based on requirements in OAR 309-032-0860 through 0870. Applicants shall:

(a) Describe their strategy for improved transitions in care so that members receive comprehensive transitional care, and members’ experience of care and outcomes are improved;

(b) Demonstrate how hospitals and specialty services are accountable to achieve successful transitions of care and establish service agreements that include the role of patient-centered primary care homes;

(c) Describe their arrangements, including memorandum of understanding, with Type B Area Agencies on Aging or the Department’s offices of Aging and People with Disabilities concerning care coordination and transition strategies for members.

(15) CCOs shall provide members with assistance in navigating the health care delivery system and accessing community and social support services and statewide resources including the use of certified or qualified health care interpreters, and Traditional Health Workers (THW). THWs include:

(a) Peer wellness specialists;

(b) Peer-support specialists;

(d) Family support specialist;

(e) Youth support specialist;

(f) Doulas; and

(g) Community health workers navigators.

(16) The applicant shall describe its planned policies for informing members about access to all types of THWs identified in OAR 950-060-0010.

(17) Services and supports shall be geographically located as close to where members reside as possible and are, when available, offered in non-traditional settings that are accessible to families, diverse communities, and underserved populations. Applicants shall describe:

(a) Delivery system elements that respond to member needs for access to coordinated care services and supports;

(b) Planned or established policies for the delivery of coordinated health care services for members in long-term care settings;

(c) Planned or established policies for the delivery of coordinated health care services for members in residential treatment settings or long-term psychiatric care settings.

(18) CCOs shall prioritize working with members who have high health care needs, multiple chronic conditions, mental illness, or Substance Use Disorder (SUD) services including members with serious and persistent mental illness covered under the state’s 1915(i) State Plan Amendment. The CCO shall involve those members in accessing and managing appropriate preventive, health, remedial, and supportive care and services to reduce the use of avoidable emergency department visits and hospital admissions. The applicant shall describe how it will:

(a) Use individualized care plans to address the supportive and therapeutic needs of each member, particularly those with intensive care coordination needs;

(b) Reflect member or family and caregiver preferences and goals to ensure engagement and satisfaction.

(19) CCOs shall participate in the learning collaborative described in ORS 413.259. Applicants shall confirm their intent to participate.

(20) CCOs shall implement to the maximum extent feasible patient‐centered primary care homes including developing capacity for services in settings that are accessible to families, diverse communities, and underserved populations:

(a) The applicant shall describe its plan to develop and expand capacity to use patient-centered primary care homes to ensure that members receive integrated, person-centered care and services and that members are fully informed partners in transitioning to this model of care;

(b) The applicant shall require its other health and services providers to communicate and coordinate care with patient‐centered primary care homes in a timely manner using health information technology.

(21) CCOs’ health care services shall be culturally and linguistically appropriate and focus on achieving health equity and eliminating health disparities. The applicant shall describe its strategy for:

(a) Ensuring health equity (including interpretation and cultural competence) and elimination of avoidable gaps in health care quality and outcomes, as measured by gender identity, race, ethnicity, language, disability, sexual orientation, age, mental health and addictions status, geography, and other cultural and socioeconomic factors;

(b) Engaging in a process that identifies health disparities associated with race, ethnicity, language, health literacy, age, disability (including mental illness and substance use disorders), gender identity, sexual orientation, geography, or other factors through community health assessment;

(c) Collecting and maintaining race, ethnicity, and primary language data for all members on an ongoing basis in accordance with standards established by the Authority.

(22) CCOs are required to use alternative payment methodologies consistent with ORS 414.598. Use of alternative payment methodologies shall be reported through the All Payer All Claims (APAC) data reporting system annually as prescribed in OAR 409-025-0125 and 409-025-0130. The applicant shall describe its plan to implement alternative payment methods alone or in combination with delivery system changes to achieve better care, controlled costs, and better health for members.

(23) CCOs shall use health information technology (HIT) to link services and care providers across the continuum of care to the greatest extent practicable. The applicant shall describe their:

(a) Initial and anticipated levels of electronic health record adoption and health information exchange infrastructure and capacity for collecting and sharing patient information electronically and its HIT Roadmap for meeting transformation expectations;

(b) Plan to support increased rates of electronic health record adoption among contracted providers, and to ensure that providers have access to health information exchange for care coordination;

(24) CCOs shall report on outcome and quality measures identified by the Authority under ORS 414.638, participate in the APAC data reporting system, and follow expectations for participation in annual TQS reporting to the Authority as detailed in the contract and external quality review with the Authority contracted External Quality Review Organization as outlined in 42 CFR §§ 438.350, 438.358, and 438.364. The applicant shall provide the following assurances:

(a) Capacity to report and demonstrate an acceptable level of performance with respect to Authority-identified metrics;

(b) Submit, or will submit, APAC data in a timely manner pursuant to OAR 409-025-0130.

(25) CCOs shall be transparent in reporting progress and outcomes. The applicant shall:

(a) Describe how it assures transparency in governance;

(b) Agree to provide timely access to certain financial, outcomes, quality, and efficiency metrics that are transparent and publicly reported and available on the Internet.

(26) CCOs shall use best practices in the management of finances, contracts, claims processing, payment functions, and provider networks. The applicant shall describe:

(a) Its planned or established policies for ensuring best practices in areas identified by ORS 414.572;

(b) Whether the CCO uses a clinical advisory panel (CAP) or other means to ensure clinical best practices;

(c) Plans for an internal quality improvement committee that develops and operates under an annual quality strategy and work plan that incorporates implementation of system improvements and an internal utilization review oversight committee that monitors utilization against practice guidelines and treatment planning protocols and policies.

(27) CCOs shall demonstrate sound fiscal practices and financial solvency and shall possess and maintain resources needed to meet their obligations:

(a) Initially, the financial applicant shall submit required financial information that allows the DCBS Division of Financial Regulation on behalf of the Authority to confirm financial solvency and assess fiscal soundness;

(b) The applicant shall provide information relating to assets and financial and risk management capabilities.

(28) CCOs may provide coordinated care services within a global budget. Applicants shall submit budget cost information consistent with its proposal for providing coordinated care services within the global budget.

(29) CCOs shall operate, administer, and provide for integrated and coordinated care services within the requirements of the medical assistance program in accordance with the terms of the contract and rule. The applicant shall provide assurances about compliance with requirements applicable to the administration of the medical assistance program.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 100-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3710 Contract Termination and Close-Out Requirements

(1) This rule applies to any termination of an MCE contract, including but not limited to non-renewal under OAR 410-141-3725, expiration of the contract at the end of its term, or termination during the term of the contract initiated by either party. Consistent with OAR 410-141-3725, MCEs shall abide by all requirements in this rule regardless of whether termination notice is provided by the Authority or the MCE.

(2) The party initiating the termination shall render written notice of termination to the other party by certified mail, return receipt requested, or in person with proof of delivery and a contemporaneous copy emailed to the other party’s contract administrator.

(3) The notice of termination shall specify the circumstances giving rise to termination and the date on which such termination shall become effective.

(4) After receipt of an MCE’s notification of intent not to renew or notice of termination, the Authority shall issue written notice to the MCE specifying:

(a) The effective date of termination;

(b) The MCE’s operational and reporting requirements; and

(5) Upon notification of termination or non-renewal, an MCE shall submit to the Authority a transition plan detailing how it fulfills its continuing obligations for the duration of the contract. The transition plan shall include:

(a) How each of the MCE’s members and contracted providers are notified of the termination of the contract;

(b) A plan to transition its members to other MCEs; and

(c) A plan for closing out its MCE business, including but not limited to the operational and reporting requirements and timelines for submission of deliverables, as specified by the Authority, and the requirements specified in this rule.

(6) Transition plans are subject to approval by the Authority:

(a) The MCE must revise the transition plan as necessary to obtain approval by the Authority;

(b) Failure to submit a transition plan and obtain written approval of the termination plan by the Authority may result in the Authority’s withholding of 20 percent of the MCE’s monthly capitation payment until the Authority has approved the transition plan;

(c) If the Authority’s approval of the transition plan occurs less than 90 days before the effective date of termination, then the Authority may require the MCE to extend the contract to a later effective date of termination, including as necessary the MCE’s acceptance of amendments to the contract generally applicable to MCE contracts through the extended effective date.

(7) The MCE shall designate an individual as the contract transition coordinator.

(8) The contract transition coordinator shall be the Authority’s contact for ensuring the MCE’s completion of the MCE’s contractual obligations, performance, operations, and member transitions including the transition plan.

(9) MCEs shall submit reports to the Authority every 30 calendar days detailing the MCE’s progress in executing its transition plan. In the event of the MCE’s substantial failure to execute timely its transition plan, the Authority may withhold 20 percent of any payments due to the MCE from the Authority until such failure is corrected.

(10) MCEs shall submit a final report to the Authority describing how it fulfilled all transition and close-out activities described in the transition plan. The final report is subject to the Authority approval before issuance of any final payment.

(11) MCEs shall continue to perform all financial, management, and administrative services obligations identified in contract throughout the closeout period, including at minimum:

(a) Restricted reserves and insurance coverage for a period of 18 months following the notice of termination, or until the state provides the MCE with written release agreeing that all continuing obligations are fulfilled, whichever is earlier;

(b) Maintaining adequate staffing to perform all required functions as specified in contract;

(c) Supplying all information necessary to the Authority or its designee upon request for reimbursement of any outstanding claims at the time of termination;

(d) Assisting the Authority to ensure an orderly transition of member services after notice of termination consistent with the Authority’s Transition of Care Policy; and

(e) To make available all signed provider agreements or subcontracts to the Authority upon request.

(12) The MCE must arrange for the orderly transfer of all OHP members assigned to the MCE to coverage under any new arrangement authorized by the Authority, including any actions required by the Authority to complete the transition of members and the termination of the MCE contract. These actions include:

(a) Forwarding of all medical or financial records related to the contractually obligated activities;

(b) High needs care coordination;

(d) Identification of chronically ill high risk, hospitalized, and pregnant members in their last four weeks of pregnancy.

(13) If a change of providers may be harmful to the member, the MCE must continue to provide services until that treatment is concluded or appropriate transfer of care is arranged.

(14) The MCE shall make available and require its providers and subcontractors to make available to the Authority copies of medical, behavioral, oral and managed long-term services and supports records, patient files, and any other pertinent information necessary for efficient care management of enrollees, as determined by the Director of the Authority:

(a) Records shall be in a usable form and shall be provided at no expense to the Authority, using a file format and dates for transfer specified by the Authority;

(b) Under no circumstances shall a Medicaid member be billed for this service;

(A) Numbers and status of grievances in process;

(B) Numbers and status of hospital authorizations in process, listed by hospital;

(D) Prior authorizations approved, pending, or denied;

(E) Program exceptions approved;

(F) Medical cost ratio data;

(G) Information on outstanding payments for medical care rendered to members;

(H) All encounter data required under the terminated agreement;

(I) Identification of members whose treatment or treatment plans require continuity of care consideration;

(J) Any other information or records deemed necessary by the Authority to facilitate the transition of care.

(15) Following expiration of the contract and the completion of closeout period obligations, the MCE shall:

(a) Maintain claims processing functions as necessary for a minimum of 18 months after the date of termination. If additional claims are outstanding, the MCE shall maintain the claims processing system as long as necessary to complete final adjudication of all claims;

(b) Remain liable and retain financial responsibility for all claims with dates of service prior to the date of termination;

(c) Maintain financial responsibility for patients who were admitted to an inpatient stay prior to the termination date through the date of discharge from their continuous inpatient stay in accordance with OARs 410-141-3500, 410-141-3805, and 410-141-3850, and to the extent the MCE is responsible under the contract;

(d) Maintain financial responsibility for services rendered prior to the termination date, for which payment is denied by the MCE and subsequently approved upon appeal by the provider; and

(e) Assist the Authority with grievances and appeals for dates of service prior to the termination date.

(16) Runout activities shall consist of the processing, payment, and reconciliations necessary regarding all enrollees, claims for payment from providers, appeals by both providers and members, and financial reporting deemed necessary by the Authority, including:

(a) Monthly claims aging report including IBNR amounts;

(b) Quarterly financial statements and annual audited financial statements in conformity with the specification in the contract up to the date specified by the Authority;

(c) Certified encounter reporting until all services rendered prior to contract expiration or termination have reached adjudicated status and the Authority data validation of the information is complete;

(d) Arranging for the retention, preservation, and availability of all records, including those records related to member grievance and appeals, litigation, base data, Medical Loss Ratio (MLR) reports, claims settlement, and those records covered under HIPAA as required by contract and state and federal law;

(e) Details of any existing third-party liability (TPL) or personal injury lien (PIL) cases and making any necessary arrangements to transfer the cases to the Authority’s TPL and PIL units; and

(f) Final reports that identify all expenditures for any period in which the MCE continued to pay claims for services provided during the contract period.

(17) The Authority may require status reports or updates to the data reporting requirements in section (16) of this rule upon request.

(18) MCEs shall submit to the Authority a written request for release certifying that all obligations have been satisfied. The Authority shall provide an official written release upon satisfaction of activities associated with the contract expiration or termination plan. The request must be signed, expressly under penalty of False Claims Act liability, by the president and the chief financial officer of the MCE and must attest that, except as expressly described in a writing attached to the attestation:

(a) All payments are received by the MCE under the contract, and all the MCE’s liabilities under the contract are extinguished;

(b) All reports, reconciliations, member matters, and provider matters are resolved and finalized; and

(c) The MCE complied with all contractual and legal requirements, including completion of the activities described in the transition plan.

(19) To the extent that the request for release under section (18) of this rule attaches any exception, the request for release must include a plan describing how each exception is resolved. Any payments due under the terms of the contract for services between the Authority and the MCE, including the distribution of restricted reserve funds or any withheld capitation amount, may be withheld until the Authority receives all written and properly executed documents from the MCE. The MCE is subject to all obligations under the contract, associated rules, and the transition plan until a final written release is issued by the Director of the Authority. Such release shall:

(a) Apply only to the extent of the MCE’s responsibilities under the MCE contract, associated rules, and the transition plan;

(b) Apply only to the extent the MCE’s submissions to the Authority are true, complete, and accurate;

(d) Not bind third parties;

(e) Not preclude the Authority’s assertion of indemnity, contribution, or other obligations based on third-party claims;

(f) Not preclude the Authority’s assertion of false claims liability, Medicaid fraud, common-law fraud, or other claims, false statements, or fraud; and

(g) Not affect any post-termination obligations of the MCE under the contract for preservation of records or for auditors’ access.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3715 CCO Governance; Public Meetings and Transparency

(1) CCOs shall establish, maintain, and operate with a governance structure and community advisory council (CAC) that is consistent with the requirements of ORS 414.625 and applicable health system transformation laws.

(2) Consumer Representative means a person serving on a CAC who is currently or was within the previous six months a recipient of medical assistance and is at least 16 years of age, or a parent, guardian, or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance.

(3) Each CCO’s governing body must include:

(a) At least one member representing persons that share in the financial risk of the organization;

(b) A representative of a dental subcontractor selected by the coordinated care organization;

(d) At least two health care providers in active practice, including:

(A) A physician licensed under ORS chapter 677 or a nurse practitioner certified under ORS 678.375, whose area of practice is primary care; and

(B) A mental health or chemical dependency treatment provider.

(e) At least two members from the community at large, to ensure that the organization's decision-making is consistent with the values of the members and the community; and

(f) At least two members of the CAC:

(A) At least one of the CAC representatives on the CCO’s governing body must be a current CAC Consumer Representative;

(B) CAC members of the governing body shall have full voting rights.

(4) For purposes of the open meetings requirement in Section 2 of Enrolled 2018 HB 4018, 2018 Oregon Laws Chapter 49, “substantive decision” means a decision made by the governing board of a coordinated care organization (CCO) that relates to:

(a) Spending of public funds;

(b) The financial risk of the CCO;

(d) The community advisory council, community health assessment, or community health improvement plan.

(5) Substantive decision does not require or include:

(a) Disclosure of trade secrets as defined in ORS 192.345;

(b) Confidential communications with a lawyer that are privileged under ORS 40.225;

(d) Protected health information as defined in ORS 192.556;

(e) Names of Oregon Health Plan consumer members of a community advisory council who request to remain anonymous;

(f) Confidential human resource matters; or

(g) Provider credentialing, sanctioning, or termination.

(6) The term “substantive decision” excludes immaterial technical decisions.

History

Statutory/Other Authority: ORS 413.042 & 414.572
Statutes/Other Implemented: ORS 414.572 & 414.590
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3720 Service Area Change for Existing CCOs

(1) For purposes of this rule, the following definitions apply:

(a) “Applicant” means a coordinated care organization (CCO) as defined in ORS 414.572 with a CCO contract with the Authority that submits an application seeking a contract amendment for a new service area. The CCO is described for purposes of this rule as the applicant upon its submission of the CCO Letter of Intent to Apply;

(b) “Document Review” means the review conducted by the Authority, occurring at the point after the receipt of the completed SAC packet and before the effective date of the contract amendment, to determine applicant’s ability to serve Medicaid beneficiaries in the requested service areas;

(c) “Letter of intent to apply (LOIA)” means a letter from a CCO to the Authority stating the CCO’s intent to submit a SAC packet in response to a service area need. An LOIA may be binding or non-binding, as specified in the Authority’s announcement of the service area need;

(d) “SAC packet” means the packet of application documents that the Authority provides to CCOs applying for a service area change (SAC);

(e) “Service Area” has the meaning provided for in OAR 410-141-3500;

(f) “Service Area Change Process” or “SAC Process” means the process the Authority uses to evaluate and approve CCO requests to expand into a new service area when a service area need exists.

(2) A CCO that desires to withdraw from all or a portion of its service area shall provide the Authority with a form Letter of Intent to Withdraw from the service area at least 120 calendar days prior to the intended date of withdrawal. The template for this form can be found on the CCO Contract Forms page. Partial withdrawals (i.e., withdrawal from only part of the service area) shall be allowed to be effective only upon written approval by the Authority. The Authority shall work with the CCO and any other impacted CCO for a workable withdrawal transition.

(3) Upon receiving written notice from a CCO of its desire to withdraw from all or part of a service area, the Authority shall acknowledge receipt and commence the withdrawal process defined in the applicable contract and in OAR 410-141-3710 (Contract Termination and Close-Out Requirements).

(a) Within a period not to exceed five (5) business days after receipt of the withdrawal notice, the Authority shall notify all contracted CCOs of:

(A) The identity of the withdrawing CCO;

(B) The geographic boundaries of the affected service area(s);

(D) The anticipated effective date of the withdrawal; and

(E) The opportunity for expansion by contracted CCOs.

(b) With the notice of withdrawal to the contracted CCOs, the Authority shall open a fourteen (14) calendar day interest period during which contracted CCOs may submit written notice of interest in expanding into the vacated service area. OHA shall provide instructions for the form and method of submitting interest;

(A) Identify the geographic areas the CCO seeks to serve;

(B) Describe how the CCO will meet network adequacy requirements consistent with OAR 410-141-3515;

(C) Outline the CCO’s proposed timeline and activities to ensure continuity of care, member protections, and care coordination consistent with OAR 410-141-3860 through 410-141-3870; and

(D) Identify any anticipated subcontracting necessary to serve the area, consistent with OAR 410-141-3505.

(d) After the interest period closes, the Authority shall review all timely submitted notices of interest to determine the feasibility of service area expansion by one or more interested contracted CCOs. If no CCO submits a notice of interest, or the one or combination of more than one CCOs submitting a notice of interest fails to meet the Authority’s criteria for assuming the vacated service area, the Authority shall initiate a service area change (SAC) process.

(4) The Authority shall determine if a service area need exists, or is anticipated to exist, when:

(a) A service area, or a portion of a service area, is being served by one CCO and that CCO is withdrawing;

(b) A CCO is withdrawing from a service area, or a portion of a service area, that has one or more additional contracted CCOs and the remaining CCO(s) are unable to meet the contractual requirements to serve the service area’s population when considering:

(A) Access to care;

(B) Service delivery;

(D) Financial performance.

(5) A service area need will not exist if:

(a) The remaining CCOs in the service area are determined to meet the contractual requirements to service the service area’s population; or

(b) One or more CCOs serving a contiguous area indicate interest to the Authority upon the initial announcement of the withdrawing CCO and are determined to meet the contractual requirements to service the service area’s population.

(6) If the Authority determines that a service area need exists:

(a) The Authority shall notify all existing CCOs that the SAC process is being initiated and that the Authority will begin accepting LOIAs. The announcement shall specify when the LOIA is due;

(b) CCOs that want to be considered for expansion into the service area shall submit their LOIAs by the deadline indicated in the Authority’s notice of the SAC process being initiated. CCOs shall designate a sole point of contact in their LOIA for this process. The Authority will not accept an LOIA or any subsequent SAC application materials from a CCO that has not submitted an LOIA by the deadline indicated in the Authority’s notice;

(c) The Authority shall send a letter of acknowledgement to the CCO within five (5) calendar days of receipt of the LOIA.

(7) Within 30 calendar days of the date specified by the Authority as the due date for submission of an LOIA, the CCO shall complete a SAC packet in its entirety and submit it to the contract administration unit at the address indicated in the SAC packet. CCOs can locate a SAC packet on the CCO Contract Forms page.

(8) CCOs applying through the SAC process outlined in this rule must meet the requirements set forth in ORS 414.572 and submit documentation as it applies to the new service area indicated in the application. Documentation requirements, based on criteria set forth in OAR 410-141-3700 and 410-141-3705, shall be included in the acknowledgement letter sent by the Authority as described in section 6(c) of this rule, which shall include, but is not limited to, information related to the following:

(a) Delivery system network and provider capacity reports highlighting any providers operating in the new service area or existing contracted providers expanding their services into the new service area;

(b) Any updates to the most recently submitted quarterly financial report;

(d) Information related to how services in the new service area will impact existing operations, including updated policies and procedures, as applicable;

(e) Information related to identifying regional, cultural, socioeconomic, and racial disparities in health care that exist among the enrollees in the new service area and establishing community support for those areas of need; and

(f) Information related to coordination of care and transfer of new members, specifically high-risk members or members with special health care needs.

(9) The Authority shall review SAC packets from all CCOs that have timely submitted an LOIA and SAC packet as required by this rule and that are considered responsive and completed as set forth in this rule.

(a) During its review of the SAC packets, the Authority may request additional information from a CCO. If additional information is requested, the CCO shall submit the additional information to the Authority within 14 days of the request.

(b) Within 30 calendar days from the date the initial SAC packets were due, the Authority shall complete its document review. This includes the final submission date for the SAC packet and receipt by the Authority of all additional requested information.

(c) To be eligible for recertification in the new service area, the applicant must meet standards established by the Authority and this rule, and be in compliance with the contract between the CCO and the Authority.

(10) The Authority shall determine which CCO(s) will be selected to serve the new service area under the procedures and criteria set forth in OAR 410-141-3700(4) and 410-141-3705.

(11) The Authority shall prepare a contract amendment for document review and signature for each CCO that receives approval to expand into the new service area. The CCO shall have 30 calendar days to return an executed contract amendment for the service area change.

(12) Applicants shall have the right to dispute any Authority actions or decisions pertaining to service area changes as set forth in OAR 410-141-3550.

History

Statutory/Other Authority: ORS 413.042, 414.625 & 414.645
Statutes/Other Implemented: ORS 413.042
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3725 CCO Contract Renewal Notification

(1) No later than 134 days prior to the end of a benefit period, the Authority shall provide each CCO with notice of the proposed changes to the terms and conditions of the contract for the next benefit period that the Authority submits to the Centers for Medicare and Medicaid Services for approval.

(2) If a CCO declines a contract renewal with the Authority, the CCO must notify the Authority of its intention not to enter into the contract renewal no later than 14 days after the Authority’s notice of proposed changes as described in section (1).

(3) A CCO’s notice to the Authority of intent not to enter into a contract renewal terminates the contract at the end of the benefit period unless:

(a) The Authority at its discretion requires the contract to remain in force into the next benefit period and be amended as proposed by the Authority until 90 days after the CCO has in accordance with criteria prescribed by the Authority:

(A) Notified each of its members and contracted providers of the termination of the contract;

(B) Provided to the Authority a plan to transition its members to other CCOs; and

(b) The Authority may at its discretion waive compliance with the deadlines stated in sections (2) or (3) if the Authority determines such waiver to be consistent with the effective and efficient administration of the medical assistance program and the protection of medical assistance recipients.

(4) A CCO that declines to renew its contract shall comply with the termination and close-out requirements in OAR 410-141-3710, except as otherwise provided in this rule.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635, 414.651 & 414.652
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3730 Community Health Assessment and Community Health Improvement Plans

(1) CCOs shall comply with the requirements in ORS 414.575, 414.577 and 414.578, as well as any requirements specified in the contract regarding the Community Health Assessment (CHA) and the Community Health Improvement Plan (CHP). To the extent a CCO shares all or part of a Service Area, the CCO must develop a shared CHA and CHP with all of the following organizations and entities: local public health authorities, community mental health programs, local planning committees, hospitals, other CCOs, and, if a federally recognized tribe has already developed or will develop their own CHA or CHP, CCOs must invite the tribe to participate in the shared CHA and CHP. These entities will be referred to as the Collaborative CHA/CHP Partners. This collaboration shall be documented in the CHA and CHP documents, inclusive of CHP progress reports.

(2) The CCOs’ CACs shall oversee, with the Collaborative CHA/CHP Partners, the development of the shared CHA.

(3) In developing and maintaining a CHA, CCOs shall, with the Collaborative CHA/CHP Partners, meaningfully and systematically engage representatives of local and tribal governments, community partners and stakeholders, and critical populations to assess the Community health needs of Contractor’s Service Area. The following must be engaged in the CHA process, without limitation:

(a) County and city government representatives;

(b) Federally recognized tribes (if not already collaborating on a shared CHA);

(d) Local mental health authorities;

(e) Physical, behavioral, and oral health care providers;

(f) Federally Qualified Health Centers;

(g) Indian Health Care Providers;

(h) Traditional Health Workers;

(i) School nurses, school mental health providers, and other individuals representing child and adolescent health services;

(j) Culturally specific organizations, including Regional Health Equity Coalitions; and

(k) Representatives from populations who are experiencing health and health care disparities.

(4) The CHA must include or identify and analyze at a minimum, all of the following:

(a) The demographics of all of the Communities within Contractor’s Service Area, including race, ethnicity, languages spoken, disabilities, age, sex, gender identity, and sexual orientation. CCOs shall work with community organizations and available data sources to obtain information on gender identity and sexual orientation if it is available;

(b) The health status and issues of all the Communities within Contractor’s Service Area;

(d) Findings on health indicators, including the leading causes of chronic disease, injury and death within Contractor’s Service Area;

(e) Findings on social determinants of health indicators across the four key domains (economic stability, education, neighborhood and built environment, social and community health);

(f) Assets and resources that can be utilized to improve the health of all of the Communities served within Contractor’s Service Area with an emphasis on determining the current status of:

(A) Access to primary prevention resources;

(B) Disproportionate, unmet, health-related needs;

(D) Systems of seamless continuum of care; and

(E) Systems or programs of collaborative governance of community benefit.

(g) Means to promote the health and early intervention in the treatment of children and adolescents within Contractor’s Service Area, and whether they are sufficient and effective;

(h) Areas for improvement; and

(i) The persons, organizations, and entities with whom Contractor collaborated and process for collaboration in creating the CHA as such persons, organizations, and entities are identified in Section (2) of this rule.

(5) CCOs and their CACs must develop baseline data on health disparities identified through the CHA process. CCOs and their CACs may collaborate with the Authority in developing this data, which includes health disparities defined by race, ethnicity, language, health literacy, age, disability, gender identity, sexual orientation, behavioral health status, geography, neighborhood and environment, or other factors. This data will be used to identify and prioritize strategies to reduce health disparities in the development of their CHPs.

(6) CCOs shall develop, review, and update its CHA at least every five years (or more often, if so requested by the Authority).

(7) Using the findings documented in their CHAs, including any health disparities data and other reliable data, CCOs shall draft a CHP, which shall serve as a strategic plan for developing a population health and health care system plan to serve the Communities within the CCOs Service Areas. Any Collaborative CHA/CHP Partners from the shared CHA, must collaborate in the development of a shared CHP. The CCOs’ CACs are responsible for adopting CHPs.

(8) In developing a CHP, CCOs shall, with the Collaborative CHA/CHP Partners, meaningfully and systematically engage representatives of local and tribal governments, community partners and stakeholders, and critical populations. The following must be engaged in the CHP process, without limitation:

(a) County and city government representatives;

(b) Federally recognized tribes (if not already collaborating on a shared CHA);

(d) Local mental health authorities;

(e) Physical, behavioral, and oral health care providers;

(f) Federally Qualified Health Centers;

(g) Indian Health Care Providers;

(h) Traditional Health Workers;

(i) School nurses, school mental health providers, and other individuals representing child and adolescent health services;

(j) Culturally specific organizations, including Regional Health Equity Coalitions; and

(k) Representatives from populations who are experiencing health and health care disparities.

(9) A CHP adopted by a CAC shall describe the health priority goals and strategies that will govern the activities and services the CCO will implement in order to address the population health needs and resources of the Community.

(a) CHP health priority goals are intended to improve the Community’s health, and may include, without limitation, issues related to:

(A) Closing the gap on disproportionate, unmet, health-related needs;

(B) Creating access to primary prevention;

(D) Building on current Community resources and improving Community capacity to improve health or address SDOH-E, or both; and

(E) Engaging the Community in the implementation of the CHP.

(b) The CHP strategies should be based on research and may include, without limitation:

(A) Developing or supporting Health Policy that supports the CHP goals and objectives;

(B) Implementing or supporting community health or SDOH-E interventions, or both, to support the CHP goals and objectives, with emphasis on evidence-based interventions as available;

(D) Designing and building a system of Integrated service delivery;

(E) Developing and implementing best practices of culturally and linguistically appropriate care and service delivery.

(d) The CHP must also address, with the input of school nurses, school mental health providers, and other individuals representing child and adolescent health services, the needs of adolescents and children in a CCO’s Service Area and must address:

(A) Findings based on research, including adverse childhood experiences;

(B) The adequacy of existing school-based health center (SBHC) networks and make recommendations relating to the improvement of, and undertake efforts that will ensure, SBHC networks meet the specific health care needs of children and adolescents in the Community;

(D) Primary care, behavioral and oral health, promotion of health and prevention, and early intervention in the treatment of children and adolescents.

(10) In addition, CACs shall annually publish a CHP progress report that evaluates and describes progress towards advancing CHP goals and strategies, addressing health disparities, and improving health equity. Progress reports will be submitted in the manner and form proscribed by OHA.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 80-2022, minor correction filed 09/30/2022, effective 09/30/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3735 Social Determinants of Health and Equity; Health Equity

(1) This rule defines health disparities and the Social Determinants Of Health and Equity (SDOH-E), establishes requirements for Supporting Health for All through Reinvestment (SHARE), establishes the role of the Community Advisory Councils in supporting SDOH-E, establishes requirements for collecting data on race, ethnicity, and primary language, and establishes requirements for developing health equity infrastructure within a Coordinated Care Organization (CCO). This rule provides structure and guidance to CCOs to support long-term, community-specific investment and partnership in SDOH-E.

(2) The following definitions apply for purposes of this rule:

(a) “Adjusted Net Income” is the pre-tax net income reported by a CCO for a calendar year (or a partial year, if relevant) pursuant to OAR 410-141-5015, adjusted by the Authority pursuant to section 3(a)(E) of this rule for items such as the following:

(A) Excessive administrative expenses, including management bonuses;

(B) Improper allocation of expenses across lines of businesses;

(D) Adjustments to base data made as part of the capitation rate development;

(E) Expenses not supported by legitimate business purposes;

(F) Payments or transfers to subcontractors, parent companies, affiliates, or subsidiaries.

(b) “Affiliate” means a person that directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with, the CCO;

(c) “Capitated Affiliate” means a CCO’s capitated subcontractor, as defined in OAR 410-141-5000, that is an affiliate of the CCO;

(d) “Control” means possessing the direct or indirect power to manage a person or set the person’s policies, whether by owning voting securities, by contract other than a commercial contract for goods or nonmanagement services, by representation on the person’s board, or otherwise, unless the power is the result of an official position or corporate office the person holds;

(e) “Health Disparities” are the structural health differences that adversely affect groups of people who systematically experience greater economic, social, or environmental obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. Health disparities are the indicators used to track progress toward achieving health equity;

(f) “Social Determinants of Health and Equity” (SDOH-E):

(A) SDOH-E encompasses three terms:

(i) The social determinants of health refer to the social, economic, and environmental conditions in which people are born, grow, work, live, and age, and are shaped by the social determinants of equity. These conditions significantly impact length and quality of life and contribute to health inequities;

(ii) The social determinants of equity refer to systemic or structural factors that shape the distribution of the social determinants of health in communities;

(iii) Health-related social needs refer to an individual’s social and economic barriers to health, such as housing instability or food insecurity.

(B) SDOH-E initiatives may involve interventions that occur outside a clinical setting, and may pursue mechanisms of change including:

(i) Community-level interventions that directly address social determinants of health or social determinants of equity;

(ii) Interventions to address individual health-related social needs.

(g) “SDOH-E Partner” is a single organization, local government, one or more of the Federally-recognized Oregon tribal governments, the Urban Indian Health Program, or a collaborative, that delivers SDOH-E related services or programs, or supports policy and systems change, or both within a CCO’s service area.

(3) The following requirements are specific to Supporting Health for All through Reinvestment (SHARE):

(a) For each calendar year starting on or after January 1, 2023, CCOs shall dedicate a portion of their previous calendar year’s adjusted net income or reserves to SDOH-E spending, pursuant to ORS 414.572(1)(b)(C) and as set forth in the contract:

(A) The portion of adjusted net income or reserves spent shall equal or exceed the greater of:

(i) A percentage of average adjusted net income for the prior three calendar years on a sliding scale based on Contractor’s Risk Based Capital (RBC) percentage as of the end of the most recent calendar year (but prior to the SHARE portion calculation); or

(ii) A proportion of the amount recorded in dividends or similar payments or both to shareholders, affiliates, or other owners in that prior year. For purposes of this section, these payments include adjusted net income earned by capitated affiliates. Capitated affiliates’ adjusted net income is calculated as defined in section 2(a) of this rule, but with respect to the capitated affiliates’ lines of business under the Contractor as reported to the Authority through Contractor’s financial statements under OAR 410-141-5015. For purposes of this section, dividends or similar payments solely designated to satisfy tax obligations of affiliates that arise on account of serving the CCO’s Oregon Health Plan members shall be excluded, provided that the CCO provides documentation which is approved by the Authority.

(B) The Authority will provide the specifications for (3)(A)(i) and (ii) of this rule, including the sliding scale to CCOs in SHARE Guidance, which is located here: https://www.oregon.gov/oha/HPA/dsi-tc/Documents/SHARE-Initiative-Guidance-Document.pdf;

(i) 300% RBC; or

(ii) The percentage referenced in OAR 410-141-5180(2) in relation to dividend payment restrictions.

(D) A CCO may dedicate more than its required minimum SHARE obligation for a given calendar year, as calculated pursuant to the requirements of (3)(a)(A)(i) and (ii), to be used toward satisfying all or a portion of the following:

(i) The current year’s SDOH-E spending requirement (e.g., excess SHARE designations reported to OHA in 2024 may be applied to a CCO’s SHARE spending in 2025); and/or

(ii) Any of the SDOH-E requirements for the three calendar years’ immediately following the date the excess SHARE designations were reported to OHA.

(E) The Authority may adjust net income under section 2(a) of this rule for the purpose of ensuring that CCOs do not calculate or distribute net income in a manner that effectively avoids or reduces SHARE spending. The Authority will present any adjustments made under this section via administrative notice to an affected CCO within 45 days of the due date for filing the financial reporting in which the SHARE obligation is determined. The notice will indicate the reasons for the adjustment and the amount of adjustment arising from each reason. The Authority will provide the CCO 30 days to reply in writing with objections or comments;

(F) The Authority may extend relief from minimum SHARE spending requirements in the event of net losses that would otherwise place the CCO’s capital, surplus or reserves below 200% RBC.

(b) CCOs shall select SDOH-E spending priorities that fall into at least one of these five domains of SDOH-E: Neighborhood and Built Environment, Economic Stability, Education, Social and Community Health, and Health Care Access and Quality, and are consistent with:

(A) The CCO’s most recent Community Health Improvement Plan (CHP) that is a shared plan with the Collaborative Partners, as defined in OAR 410-141-3730, including local public health authorities and local hospitals. If the CCO has not yet developed a shared CHP, the CCO shall align its priorities with those identified in CHPs developed by other stakeholders in the service area, such as local public health authorities, hospitals, and other CCOs; and

(B) Any SDOH-E priority areas identified by the Authority.

(c) A portion of SHARE dollars must go directly to SDOH-E Partner(s) for the delivery of services or programs, policy, or systems change, or any of these, to address the social determinants of health and equity as agreed by the CCO. CCOs shall enter into a contract, a Memorandum of Understanding, or other form of agreement including a grant agreement, with each SDOH-E Partner that defines the services to be provided and the CCO’s data collection methods as provided in the contract between the Authority and the CCO;

(d) SHARE expenses are not required to meet the requirements of 45 CFR 158.150(b) and are paid for with funding separate from premium revenue. Therefore, SHARE expenses do not need to be considered “activities that improve health care quality” under 45 CFR 158.150(b) and are not included in Medical Loss Ratio (MLR) as defined in 42 CFR 438.8;

(e) CCOs shall report completed and anticipated SDOH-E expenditures using the format specified by the Authority. These reports will be posted publicly.

(4) Community Advisory Councils (CAC):

(a) CCOs shall designate a role for the CAC in SHARE spending decisions;

(b) CCOs shall have a conflict of interest policy that applies to its CAC members and accounts for financial interests related to SHARE and other SDOH-E spending;

(c) CCOs shall submit reports to the Authority no less than annually that describes the CAC’s role in making decisions on these issues. These reports will be posted publicly with appropriate redactions.

(5) CCOs shall collect and maintain data on race, ethnicity, and primary language for all members on an ongoing basis in accordance with standards established by the Authority, including REAL-D. CCOs shall track and report on any quality measure by these demographic factors. The CCOs shall make this information available by posting on the web.

(6) Health Equity Infrastructure:

(a) The term “Health equity infrastructure” refers to the adoption and use of culturally and linguistically responsive models, policies and practices including and not limited to:

(A) Community and member engagement;

(B) Provision of quality language access;

(D) ADA compliance and accessibility of CCO and provider network;

(E) ACA 1557 compliance;

(F) CCO and provider network organizational training and development;

(G) Implementation of the CLAS Standards;

(H) Non-discrimination policies.

(b) The “Health Equity Plan" is part of the "Health Equity Infrastructure";

(A) Develop and implement the “Health Equity Plan” to embed health equity as a value and business practice into organizational policies, procedures, and processes;

(B) Meet state and federal laws and contractual obligations regarding accessibility and culturally and linguistically responsive health care and services;

(D) Provide a structure to ensure oversight and management of programs and services with the goal to advance health equity and provide culturally and linguistically appropriate services.

(d) The Health Equity Plan shall include the following:

(A) Narrative of the Health Equity Plan development process, including description of meaningful community engagement;

(B) Health equity focus areas, including strategies, goals, objectives, activities and metrics;

(i) CCO shall incorporate Cultural Responsiveness and implicit bias continuing education and training into its existing organization-wide training plan and programs;

(ii) CCO shall align cultural responsiveness and implicit bias trainings with the “Cultural Competence Continuing Education” criteria developed by the Authority’s Cultural Competence Continuing Education Advisory Committee referenced in OAR 950-040-0020;

(iii) CCO shall adopt the definition of Cultural Competence set forth in OAR 950-040-0010;

(iv) CCO shall provide and require all its employees, including directors, executives, and CAC members to participate in all such trainings;

(v) CCO’s shall require all CCO’s Provider Network to comply with Cultural Competency Continuing Education requirements set forth in ORS 676.850.

(e) The Health Equity Plan and the language access self-assessment report are required to be submitted under OAR 410-141-3515 and shall be submitted every year to the Authority for review and approval;

(f) CCOs shall designate a Single Point of Accountability. The single point of accountability can also be called the Health Equity Administrator:

(A) The Single Point of Accountability ("Health Equity Administrator") shall be responsible and accountable for all matters relating to Health Equity within the CCO, CCO Provider Network and CCO service area;

(B) The Single Point of Accountability ("Health Equity Administrator”) shall have budgetary decision-making authority and health equity expertise;

(C) The Single Point of Accountability (“Health Equity Administrator") shall be a high-level employee (e.g., director level or above) and can have more than one area of responsibility and job title;

(D) The CCO shall inform and describe to the Authority any changes related to the “Health Equity Administrator” role or scope using the Health Equity Plan;

(E) The Single Point of Accountability ("Health Equity Administrator") shall have the authority to communicate directly with CCO executives and governing board.

History

Statutory/Other Authority: ORS 413.042, 414.575, 414.578, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 56-2025, amend filed 06/27/2025, effective 07/01/2025
DMAP 101-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3740 Traditional Health Workers

(1) The Authority requires that all CCO members based on their health needs must have access to certified traditional health workers (THWs) who are part of the member’s care team in clinical and community-based settings to ensure members have improved access to appropriate services. The THWs, as a part of the member’s care team, must participate in processes affecting the member’s care and service needs. THW is defined in OAR 950-060-0010.

(2) CCOs shall develop and implement a plan for integrating and utilizing THWs, in accordance with this rule and the CCO contract:

(a) THW integration and utilization plans shall include:

(A) Information on THW access and usage for CCO members;

(B) Benchmarks and measurement of baseline data for integration and utilization of THWs;

(b) THW integration and utilization plans shall be submitted to OHA as required under the contract.

(3) CCOs shall establish, based on OHA’s and the Traditional Health Worker Commission guidelines, a THW payment grid that includes alternative and sustainable payment strategies. Each CCO shall provide its THW Payment Grid to OHA. OHA will then post each CCOs Payment Grid to make them publicly available.

(4) CCOs shall designate a THW liaison, who shall serve as the central point of contact for THW integration.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 102-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3800 CCO Enrollment for Children Receiving Health Services

(1) Pursuant to OAR 410-141-3805, the Authority or Oregon Youth Authority (OYA) shall select CCOs for a child receiving services in an area where a CCO is available.

(2) The Authority shall to the maximum extent possible ensure that all children are enrolled in CCOs at the next available enrollment date following eligibility determination, redetermination, or upon review by the Authority unless the Authority authorizes disenrollment from a CCO:

(a) Except as provided in OAR 410-141-3805 (Coordinated Care Enrollment Requirements), 410-141-3810 (Disenrollment from Coordinated Care Health Plans), or ORS 414.631(2), children are not exempt from mandatory enrollment in a CCO on the basis of third-party resources (TPR) coverage consistent with OAR 410-141-3805;

(b) The Authority shall review decisions to use fee-for-service (FFS) open card for a child if the child’s circumstances change and, at the time of redetermination, shall consider whether the Authority shall enroll the child in a CCO.

(3) When a child is transferred from one CCO to another CCO or from FFS to a CCO, the CCO shall facilitate coordination of care consistent with OAR 410-141-3860:

(a) CCOs shall work closely with the Authority to ensure continuous CCO enrollment for children;

(b) If the Authority determines that it should disenroll a child from a CCO, the CCO shall continue to provide health services until the Authority’s established disenrollment date to provide for an adequate transition to the next CCO;

(4) When a child experiences a change of placement that may be permanent or temporary, the Authority shall verify the address change information to determine whether the child no longer resides in the CCO’s service area:

(a) A temporary absence as a result of a temporary placement out of the CCO’s service area does not represent a change of residence if the Authority determines that the child is reasonably likely to return to the CCO’s service area at the end of the temporary placement;

(b) Children receiving children, adult, and family services from the Department who are eligible to be enrolled with the CCO serving the geographic area of placement: Department representatives may request a service area exception (SAE) to maintain CCO coverage on a placement they consider temporary;

(c) Children in OYA custody who are eligible to be enrolled with the CCO serving the geographic area of placement: OYA representatives may request a service area exception (SAE) to maintain CCO coverage on a placement they consider temporary.

(5) If the Authority enrolls the child in a CCO on the same day the child is admitted to psychiatric residential treatment services (PRTS), the CCO shall coordinate care and pay for covered health services during that placement even if the location of the facility is outside the CCO’s service area:

(a) The child is presumed to continue to be enrolled in the CCO with which the child was most recently enrolled. The Authority considers an admission to a PRTS facility a temporary placement for purposes of CCO enrollment;

(b) Any address change associated with the placement in the PRTS facility is not a change of residence for purposes of CCO enrollment and may not be a basis for disenrollment from the CCO unless the provisions in OAR chapter 410, division 141 apply;

(c) If the Authority determines that a child was disenrolled for reasons not consistent with these rules, the Authority shall re-enroll the child with the appropriate CCO and assign an enrollment date that provides for continuous coverage with the appropriate CCO. If the child was enrolled in a different CCO in error, the Authority shall disenroll the child from that CCO and recoup the CCO payments.

(6) Except for OAR 410-141-3805 and 410-141-3810, if a child is enrolled in a CCO after the first day of an admission to PRTS, the enrollment effective date shall be immediately upon discharge.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3805 Mandatory MCE Enrollment Exceptions

(1) In addition to the definitions in OAR 410-120-0000, the following definitions apply:

(a) “Eligibility Determination” means an approval or denial of eligibility and a renewal or termination of eligibility as set forth in OAR 410-200-0015;

(b) “Newly Eligible” means recently determined through the eligibility determination process as having the right to obtain state health benefits, satisfying the appropriate conditions;

(c) “Renewal” means a regularly scheduled periodic review of eligibility resulting in a renewal or change of program benefits, including the assignment of a new renewal date or a change in eligibility status;

(d) “Healthier Oregon” and “Healthier Oregon Cover All Kids” means the benefit packages described in OAR 410-134-0003;

(e) Compact of Free Association (COFA) Dental Program means the benefit package described in OAR 410-120-1210;(f) Veteran Dental Program means the benefit package described in OAR 410-120-1210.

(f) “Citizenship Waived Medical (CWM) Benefits Package” means the benefit package described in OAR 410-134-0005(2), which ended on June 30, 2023;

(g) “Citizenship Waived Medical Plus (CWM) Benefit Package” means the benefit package described in OAR 410-134-0005(2), which was previously referred to as CWX and ended on June 30, 2023.

(2) CCO enrollment is mandatory in all areas served by a CCO. A client eligible for or receiving health services shall enroll in a CCO as required by ORS 414.631, except as provided in ORS 414.631(2), (3), (4) and (5), and this rule.

(3) MCE enrollment is mandatory in service areas with adequate access and capacity to provide health care services through an MCE. If upon application or redetermination a client does not select an MCE, the Authority shall auto-assign the client and the client’s household to an MCE that has adequate access and capacity. Enrollment may vary depending on which options are available in the member’s service area at the time of enrollment:

(a) The member shall be enrolled with a CCO that offers bundled physical health, behavioral health, and dental services, which is the CCOA plan type;

(b) The member shall be enrolled with a CCO for physical health and behavioral health services and shall remain fee-for-service (FFS) for dental services, which is the CCOB plan type;

(c) The member shall be enrolled with a CCO for behavioral health and dental services and shall remain FFS for physical health services, which is the CCOG plan type;

(d) The member shall be enrolled with a CCO for behavioral health services and shall remain FFS for physical health services and dental services, which is the CCOE plan type;

(e) The member shall be enrolled with a CCO for dental services and remain FFS for physical health and behavioral health services, which is the CCOF plan type;

(f) The member shall remain FFS for health care services if no MCE is available; or

(g) Members eligible for the Compact of Free Association (COFA) Dental Program or the Veteran Dental Program benefit packages shall be enrolled in a CCO for dental services. Pharmacy services covered under these benefit packages are Carve-Out Services paid by the Authority through the Oregon Prescription Drug Program.

(4) MCE enrollment is voluntary in service areas without adequate access and capacity to provide health care services through an MCE.

(5) If a service area changes from mandatory enrollment to voluntary enrollment while a member is enrolled with an MCE, the member shall remain enrolled with the MCE for the remainder of their eligibility period or until the Authority or Department redetermines their eligibility, whichever comes first, unless the member is otherwise eligible to disenroll pursuant to OAR 410-141-3810.

(6) Members who are exempt from physical health services shall receive behavioral health services and dental services through an MCE. The member shall:

(a) Be enrolled with a CCO that offers behavioral health and dental services;

(b) Be enrolled with a CCO for dental services and shall remain FFS for behavioral health services; or

(7) If the member qualifies for enrollment into an MCE, the following pertains to the effective date of the enrollment:

(a) The Authority shall enroll within three (3) days following eligibility, redetermination, or upon review by the Authority. If the member does not submit an MCE preference they will be enrolled within five (5) days.

(b) Newly eligible members that qualify for MCE enrollment shall receive health care services on a fee-for-service (FFS) basis until they are enrolled into an MCE.

(8) Coordinated care services shall begin as of the effective date of enrollment with the MCE except for:

(a) A newborn’s enrollment shall begin on the date of birth if the mother was a member of a CCO and the newborn is OHP eligible at the time of birth;

(b) For adopted children or children placed in an adoptive placement, the date of enrollment shall be the date specified by the Authority.

(9) The following populations may not be enrolled into an MCE, as indicated below in this rule, for any type of health care coverage or for the type of coverage specified:

(a) Individuals eligible for OHP through the Healthier Oregon or Healthier Oregon Cover All Kids benefit package described in OAR 410-134-0003, but for whom the Authority has not provided capitation or other payment rates in the applicable CCO contract;

(b) Clients with Medicare receiving premium assistance through the Specified Low-Income Medicare Beneficiary, Qualified Individuals, Qualified Disabled Working Individuals and Qualified Medicare Beneficiary programs without another Medicaid;

(c) Individuals who are dually eligible for Medicare and Medicaid and enrolled in a program of all-inclusive care for the elderly (PACE);

(d) Before June 30, 2023, individuals eligible for CWM or CWX (CWX began being referred to as CWM Plus effective July 1, 2023) benefit packages described in OAR 410-134-0005(2).

(10) Individuals currently enrolled with an Indian Managed Care Entity (IMCE) consistent with OAR 410-146-5000 may not also be enrolled in the CCOA or CCOB plan type.

(11) If enrollment action coincides with an individual’s Continuous Inpatient Stay as defined in OAR 410-141-3500, the following enrollment rules apply:

(a) A newly eligible OHP client who became eligible while admitted as an inpatient is exempt from all levels of CCO enrollment, except for newborn enrollments in accordance with OAR 410-141-3805(8)(a). The newly eligible OHP client shall receive health care services on a Fee-For-Service (FFS) basis until the individual is discharged from the continuous inpatient stay;

(b) In settings where the CCO is fully responsible for covered services, such as an acute care hospital, acute care psychiatric hospital, skilled nursing facility specific to the Post-Hospital Extended Care (PHEC) benefit, Psychiatric Residential Treatment Facility (PRTF), or a residential Behavioral Health or Substance Use Disorder treatment facility that is not considered a Home and Community-Based Services (HCBS) setting as described in OAR 410-173-0035:

(A) The CCO is responsible for covered services if the individual is enrolled as of the date they are admitted to the inpatient setting. No enrollment changes shall be made until the member is discharged from their continuous inpatient stay to ensure continuity of care and care coordination, and to mitigate billing confusion;

(B) If the individual is enrolled in a CCO after the first day of admission to the inpatient setting, the enrollment shall be cancelled as never effective and the date of enrollment shall be the next available enrollment date following discharge from the continuous inpatient stay to ensure continuity of care and care coordination, and to mitigate billing confusion;

(C) When a justice-involved individual, meeting the definition for Inmate stated within OAR 410-200-0015, is admitted to an inpatient setting with an expected stay of at least 24 hours, the individual temporarily resumes OHP eligibility and the inpatient stay is covered by FFS; CCO enrollment shall be the next available enrollment date following release from the penal facility as consistent with OAR 410-200-0140, OAR 461-135-0950, and OAR 410-141-3810, and based on the service area of the member’s current permanent residence.

(c) In settings where the CCO is responsible for care coordination but not health services, including, but not limited to Medicaid-Funded Long Term Services and Supports (LTSS) or Behavioral Health Carve-Out Services:

(A) Contractor is responsible for care coordination if the individual is enrolled as of the date they are admitted to the inpatient setting. No enrollment changes shall be made (CCO-to-FFS, CCO-to-CCO, or FFS-to-CCO) until the member is discharged from their continuous inpatient stay to ensure continuity of care coordination;

(B) If the individual is enrolled in a CCO after the first day of admission to the inpatient setting, the enrollment shall be cancelled as never effective, and the date of enrollment shall be the next available enrollment date following discharge from the continuous inpatient stay to ensure continuity of care coordination;

(C) When a resident of a public institution, as defined in OAR 461-135-0950, is voluntarily or involuntarily admitted to the Oregon State Hospital, OHP eligibility is suspended and any associated CCO enrollment is ended with an effective date of the inpatient admission; however, the CCO is responsible for care coordination.

(d) If an individual is currently experiencing an extended but temporary hold within an Emergency Department due to unavailability of inpatient placement or delay in secure transportation to a facility that can evaluate appropriate psychiatric referrals, no enrollment changes shall be made (CCO-to-FFS or CCO-to-CCO) until the individual is no longer in the Emergency Department or, if subsequent action is admission to an inpatient setting, until the individual is discharged from their continuous inpatient stay.

(12) A client may not be enrolled with a CCO in the CCOA, CCOB, CCOE, or CCOG plan type if the client is covered under a major medical insurance policy, Third Party Liability (TPL), or other Third-Party Resource (TPR) that covers the cost of services to be provided by a CCO as specified in ORS 414.631 and except as provided for children in Child Welfare through the Behavior Rehabilitation Services (BRS) and Psychiatric Residential Treatment Services (PRTS) programs outlined in OAR 410-141-3800:

(a) A client shall be enrolled with a CCO in the CCOF plan type for dental services even if they have a dental TPR;

(b) At the Authority’s discretion, a client shall be enrolled with the highest level of CCO coverage, including physical health, behavioral health, and dental services, if coverage through the TPR poses a safety risk to the member, specific to Good Cause determination as described in OAR 461-120-0350(1) and OAR 410-200-0220(6). In these situations:

(A) Recovery of third-party insurance shall not be pursued; and

(B) Explanation of Benefits (EOB) shall be suppressed.

(13) Individuals who are American Indian and Alaskan Native (AI/AN) beneficiaries per OAR 410-141-3500(41) are exempt from mandatory enrollment into an MCE, except for IMCE enrollment per OAR 410-146-5000.

(14) A child in the legal custody of the Department or where the child is expected to be in a substitute care placement for less than 30 calendar days is exempt from mandatory enrollment for physical health services from a CCO but is subject to mandatory enrollment into both behavioral and dental services as available in the member’s service area unless:

(a) Access to health care on an FFS basis is not available; or

(b) Enrollment preserves continuity of care. In these cases, the member may be manually enrolled into a physical health plan or remain enrolled as deemed appropriate by the Authority.

(15) Clients who are dually eligible for Medicare and full Medicaid but not enrolled in a program of all-inclusive care for the elderly (PACE) may be automatically enrolled into an MCE. The following apply to automated duals enrollment:

(a) The dually eligible Medicare and Medicaid client shall receive choice counseling on Medicare-Medicaid options at their request from a local APD/AAA office or other Department or Authority designated entity, as well as information on the benefits for clients in aligning Medicare and Medicaid;

(b) If a client is already enrolled in a Medicare Advantage or Dual Special Needs Plan (D-SNP), the member shall be enrolled into an affiliated CCO if one exists. Otherwise, the client shall be enrolled in a CCO available to the member based on the member’s residential address or home geographic region;

(c) A full Medicare and Medicaid dually eligible member may request to opt out of enrollment for physical health services from a CCO but is subject to mandatory enrollment into both behavioral and dental services as available in the member’s service area. Disenrollment requests are subject to review or delay as deemed appropriate by the Authority when:

(A) Access to health care on an FFS basis is not available; or

(B) Enrollment preserves continuity of care. In these cases, the member has a condition, treatment, or specialized consideration that requires individual care transition, members may not be disenrolled without review and approval by the Authority. The Authority shall consider the following in its review;

(i) The development of a prior-authorized treatment plan;

(ii) Care management requirements based on the beneficiary's medical condition;

(iii) Transitional care planning including but not limited to hospital admissions/discharges, palliative and hospice care, long-term care and services; and

(iv) Need for individual case conferences to ensure a "warm hand-off."

(d) The following choices of plans shall be extended to dually eligible Medicare-Medicaid clients or members with full Medicaid as follows:

(A) The option to enroll in a CCO regardless of whether they are enrolled in an affiliated Medicare Advantage, enrolled in Medicare Advantage with another entity, or if the member remains in FFS Medicare;

(B) The option to enroll in a CCO when enrolled in Medicare Advantage, whether or not they pay their own premium, even if the MCE does not have a corresponding Medicare Advantage plan;

(e) The CCO shall accept the client’s enrollment if the CCO has adequate health access and capacity;

(f) CCO care coordination and communication requirements to reduce duplication of care planning activities in OAR 410-141-3860 and OAR 410-141-3870 are required regardless of the member’s choices in Medicare and Medicaid enrollments.

(16) The Authority may temporarily exempt clients for other just causes as determined by the Authority through medical review. The Authority may set an exemption period on a case-by-case basis for those as follows:

(a) Children under 19 years of age who are medically fragile and who have special health care needs. The Authority may enroll these children in CCOs on a case-by-case basis. Children not enrolled in a CCO shall continue to receive services on a FFS basis;

(b) The following apply to clients and exemptions relating to organ transplants:

(A) Newly eligible clients are exempt from enrollment with a CCO if the client is newly diagnosed and under the treatment protocol for an organ transplant;

(B) Newly eligible clients with existing transplants are not exempt from enrollment unless the Authority determines there are other just causes to preserve the continuity of care.

(17) MCE enrollment standards:

(a) MCEs shall remain open for enrollment unless the Authority has closed enrollment. Reasons for closing enrollment may include:

(A) The MCE has exceeded its enrollment limit or does not have sufficient capacity to provide access to services, as mutually agreed upon by the Authority and the MCE;

(B) Closed enrollment as a sanction for MCE misconduct.

(b) MCEs shall accept all eligible potential members, regardless of health status at the time of enrollment, subject to the stipulations in contracts/agreements with the Authority to provide covered services;

(A) The individual's name appears on the monthly or daily enrollment list produced by the Authority;

(B) The individual presents a valid medical care identification that shows they are enrolled with the MCE;

(D) An appropriately authorized staff member of the Authority states that the individual is currently eligible and enrolled with the MCE.

(d) MCEs shall have open enrollment for thirty (30) continuous calendar days during each 12-month period of January through December, regardless of the MCE’s enrollment limit. The open enrollment periods for consecutive years may not be more than fourteen (14) months apart;

(e) OHA may increase a CCO’s enrollment capacity as needed in response to unforeseen events or legislative changes impacting the number of eligible members in one or more plan regions;

(f) MCEs may request increases to their maximum enrollment capacity for one or more regions when member enrollment meets or exceeds 95 percent of contract maximum, subject to OHA approval.

(18) If the Authority permits an MCE to assign its contract to another MCE, members shall be automatically enrolled in the MCE that has assumed the contract:

(a) Each member shall have thirty (30) calendar days from the date of notice of enrollment to request disenrollment from the MCE that has assumed the contract;

(b) If the MCE that has assumed the contract is a Medicare Advantage plan, those members who are Medicare beneficiaries shall not be automatically enrolled but shall be offered enrollment in the succeeding MCE.

(19) If an MCE engages in an activity such as the termination of a participating provider or participating provider group that has significant impact on access in that service area such that the MCE cannot meet the access to care requirements set forth in OAR 410-141-3515 and which necessitates either transferring members to other providers or the MCE withdrawing from part or all of a service area, the MCE shall provide the Authority at least ninety (90) calendar days written notice before the planned effective date of such activity:

(a) An MCE may provide less than the required ninety (90) calendar-day notice to the Authority upon approval by the Authority when the MCE must terminate a participating provider or participating provider group due to problems that could compromise member care, or when such a participating provider or participating provider group terminates its contract with the MCE and refuses to provide the required ninety (90) calendar-day notice;

(b) The MCE shall provide members with at least a thirty (30) calendar-day notice of such changes. In the event the MCE is not available to provide members with notice of a change in participating providers or MCE, the Authority shall instead notify members of a change in participating providers or MCEs. In such instances the MCE shall provide the Authority with the name, prime number, and address label of the members affected by such changes at least thirty (30) calendar days before the planned effective date of such activity.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 35-2025, amend filed 03/28/2025, effective 04/01/2025
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 124-2024, amend filed 09/27/2024, effective 10/01/2024
DMAP 90-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 19-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3810 Disenrollment from MCEs

(1) Member-initiated requests for disenrollment.

(a) All member-initiated requests for disenrollment from an MCE shall be initiated orally or in writing by the primary person in the benefit group enrolled with an MCE where primary person and benefit group are defined in OAR 461-001-0000, 461-001-0035, and 461-110-0750, respectively. For members who are not able to request disenrollment on their own, the request may be initiated by the member’s representative. Some disenrollment requests may not be applicable to all MCEs. In instances where that is the case, the type of MCE is specified within the applicable section or subsection of this rule;

(b) The Authority or MCE shall honor a member or representative request for disenrollment for the following reasons:

(A) Without cause:

(i) Members may request to change their MCE enrollment within thirty (30) calendar days of the Authority’s automatic or manual enrollment error. If approved, the change would occur on the next available enrollment date;

(ii) Members may request to change their MCE enrollment within ninety (90) calendar days of the initial MCE enrollment. If approved, the change would occur on the next available enrollment date;

(iii) Members may request to change their MCE enrollment after they have been enrolled with the MCE for at least six (6) months. If approved, the change would occur at the end of the month;

(iv) Members may request to change their MCE enrollment at their OHP eligibility renewal. If approved, the change would occur at the end of the month;

(v) Members have one additional opportunity to request a plan change during the eligibility period if none of the above options can be applied. If a request for disenrollment is approved under this section, the change would occur at the end of the month.

(B) With cause, at any time as follows:

(i) The member moves out of the MCE service area; or

(ii) Due to moral or religious objections the MCE does not cover the service the member seeks;

(iii) When the member needs related services (for example a Caesarean section and a tubal ligation) to be performed at the same time, not all related services are available within the network, and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk.

(C) Medicare and Medicaid fully dual eligible members may change plans or disenroll to FFS at any time subject to the provisions set forth in OAR 410-141-3805(14)(c) based on enrollment options in the member’s service area and to ensure continuity of care during a transition;

(D) Other reasons including, but not limited to, poor quality of care, lack of access to services covered under the contract, or lack of access to participating providers who are experienced in dealing with the specific member’s health care needs. Examples of sufficient cause include but are not limited to:

(i) The member is an American Indian or Alaskan Native with proof of Indian Heritage who wishes to obtain primary care services from their Indian Health Service facility, tribal health clinic/program, or urban clinic and the FFS delivery system;

(ii) The member is at risk of experiencing a lack of continuity of care. Continuity of care for the purpose of this rule means the ability to sustain services necessary for a person's treatment. A request for disenrollment based on continuity of care shall be denied if the basis for this request is primarily for the convenience or preference of a member for a provider of a treatment, service, or supply:

(I) A request for disenrollment based on continuity of care shall be deemed by the Authority a request for an open card for continuity of care and a temporary MCE exemption;

(II) Authority decisions to approve or deny the member’s request shall be communicated in a written notice to the member. A Copy of the notice shall be sent, if applicable, to the providers that participated in the member’s request. The notice to the member shall include the regulatory or clinical criteria, or both, relied upon to make the decision cited in the notice. If the Authority’s decision is a denial of a request for disenrollment, the notice shall include information about the member’s right to, and how to, file a grievance and other information related to the member’s administrative hearing rights;

(E) If thirty (30) calendar days pass without a decision from the Authority on a member’s disenrollment request, the request becomes effective on the first calendar day of the following calendar month (unless the Authority takes action before that date).

(A) A temporary enrollment request shall be granted if a member is at any point in the third trimester of pregnancy and:

(i) The member is newly determined eligible for OHP; or

(ii) The member is newly re-determined eligible for OHP and not enrolled in a MCE within the past three (3) months; or

(iii) The member is enrolled with a new MCE that does not contract with the member’s current OB provider and the member wishes to continue obtaining maternity services from that non-participating OB provider.

(B) The enrollment exemption shall remain in place until sixty (60) calendar days postdate of either the delivery of the member’s child or the pregnancy otherwise ends, at which time the member shall be enrolled in the appropriate MCE in their service area. Where there is a choice among multiple MCEs in the member’s service area the member may choose an open plan; however, if the member does not express preference, the Authority shall auto assign on a next weekly basis.

(d) Upon approval of a member’s disenrollment from a MCE, the member shall join another MCE unless:

(A) The member resides in a service area where enrollment is voluntary;

(B) The member meets the exemptions to enrollment set forth in OAR 410-141-3805;

(D) There is not another MCE available and open to new enrollment in the service area.

(2) MCE-initiated disenrollment requests for reasons other than fraudulent or illegal acts, uncooperative or disruptive behavior, or credible threats of violence: MCEs may request disenrollment for any of the following reasons. Such requests shall be submitted to the Authority’s Client Enrollment Services (CES) unit unless otherwise specified. After review of all necessary documentation submitted with an MCE’s request, the Authority shall grant such requests, except the Authority may deny requests based on the reason set forth in subsection (g) below:

(a) If the individual is enrolled after the first day of admission to an inpatient setting, the enrollment shall be cancelled as never effective and the individual shall be enrolled in a MCE on the next available enrollment date following discharge from the continuous inpatient stay. This does not apply if the member is a newborn child born to an OHP eligible mother enrolled with an MCE at time of birth in accordance with OARs 410-141-3500 and 410-141-3805;

(b) If the MCE determines the member has Third Party Liability (TPL), the MCE shall report the TPL to the Authority’s Health Insurance Group (HIG) on the webform located at https://www.oregon.gov/dhs/business-services/opar/pages/tpl-hig.aspx. The MCE shall receive an emailed tracking number following the online report. The MCE may use this number, should they choose to follow up on their referral submission via the provider portal. If the member is determined to have active TPL, the member shall be disenrolled from the MCE effective at the end of the month the TPL is reported, with the exception of:

(A) When Good Cause determination is active or concurrently documented, in which case the member shall retain the highest level of CCO coverage as set forth in OAR 410-141-3805(10)(b);

(B) Some situations in which the Authority may approve retroactive disenrollment;

(c) If a member has been residing outside the MCE’s service area for more than three (3) months unless previously arranged with the MCE, and the member is unable to be reached or has not responded to MCE requests to contact the Authority to update their address. The MCE shall provide written documentation that the member has been residing outside its service area for more than three (3) months. The proof shall be provided along with the initial request for disenrollment to the CCO account representative (CCO AR) for validation and a decision. The CCO AR shall notify the MCE of the approval or denial and rational for the decision. If approved, the effective date of disenrollment shall be the date specified by the Authority, and if a partial month remains, the Authority shall recoup the balance of that month’s capitation payment from the MCE;

(d) If the member is an inmate who is serving time for a criminal offense or confined involuntarily in a state or federal prison, jail, detention facility, or other penal facility. This does not include members on probation, house arrest, living voluntarily in a facility before or after their case has been adjudicated, infants living with an inmate, or inmates who become inpatients. The MCE shall identify the members and provide sufficient written proof of incarceration to the Authority for review of the disenrollment request. The Authority shall retroactively disenroll or suspend enrollment when the member has been taken into custody. The effective date of any disenrollment approved by the Authority shall be the date the member was incarcerated;

(e) If, prior to January 1, 2022 (or later if specified by the Authority), the member is in a state psychiatric institution. After December 31, 2021 (or later if specified by the Authority) the Authority shall not automatically grant requests for disenrollment based solely on a member’s admission to a state psychiatric institution;

(f) The Medicare member is enrolled in a Medicare Advantage plan and was receiving hospice services at the time of enrollment in the MCE;

(g) The member had End Stage Renal Disease at the time of enrollment in the MCE.

(3) MCE Disenrollment Requests: Fraudulent or Illegal Acts.

(a) MCEs have the right to request the Authority disenroll members from the MCE when they commit fraudulent or illegal acts related to participation in the OHP such as: Permitting the use of their medical ID card by others, altering a prescription, theft, or other criminal acts;

(b) The MCE shall report any illegal acts by an MCE member to law enforcement authorities and to the ODHS Fraud Investigations Unit;

(c) When requesting disenrollment based on an MCE member’s fraudulent or illegal act(s), the MCE shall submit a written disenrollment request to its CCO AR at the Authority. In the disenrollment request, the MCE shall document the reasons for the request, provide written evidence to support the basis for the request, including any verification of reports submitted to law enforcement and the ODHS Fraud Investigations Unit;

(d) Based on the evidence presented, the CCO AR shall review the disenrollment request and all submitted evidence with Authority staff. The review process shall be documented and a recommendation for disenrollment shall be submitted to the Authority’s management to make a final decision on the appropriateness of disenrolling a member from the MCE and whether any recommended disenrollment decision must be made immediately or wait until after the completion of any fraud investigation.

(4) MCE Disenrollment Requests: Uncooperative or Disruptive Behavior.

(a) Subject to applicable disability discrimination laws and section (4) of this rule, the Authority may, upon request of an MCE, disenroll members for cause when a member is uncooperative or disruptive, except when such behavior is the result of the member’s special health care needs or disability. A member’s refusal to accept a provider’s treatment plan does not constitute uncooperative or disruptive behavior for purposes of this rule;

(b) For purposes of this rule, a “direct threat” means a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures. In determining whether a member poses a direct threat to the health or safety of others, the MCE shall make an individualized assessment based on reasonable judgment that relies on:

(A) Current medical knowledge or the best available objective evidence to ascertain the nature, duration, and severity of the risk to the health or safety of others;

(B) The probability that potential injury to others shall actually occur; and

(A) Physical, intellectual, developmental, or mental disability; or

(B) An adverse change in the member’s health; or

(D) Filing a grievance or exercising any appeal or contested case hearing rights; or

(E) The member exercises their option to make decisions regarding their medical care with which the MCE disagrees; or

(F) Uncooperative or disruptive behavior resulting from the member’s special needs.

(d) MCEs shall require their providers to provide the MCE with prompt written notification of a member’s uncooperative or disruptive behavior. The provider’s notification shall describe the uncooperative or disruptive behavior and, except as provided for in section (5) of this rule, allow time for appropriate resolution by the MCE before refusing to provide services to the member. The provider shall document the written notification to the MCE in the member's medical record;

(e) In response to notification of a member’s uncooperative or disruptive behavior, the MCE shall do all of the following prior to submitting a request for disenrollment:

(A) Furnish education and training to the notifying provider about the need for early intervention, disability accommodation, and the resources or services available to the provider. The MCE shall document the education, training, and the resources or services furnished to the reporting provider;

(B) Contact the member either in person, by telephone, or in writing. All contacts made in person or by telephone shall be followed by written confirmation and sent to the member with a copy to the provider that notified the MCE of the member’s uncooperative or disruptive behavior. When contacting the member, the MCE shall:

(i) Inform the member of the uncooperative or disruptive behavior that has been identified and attempt to develop an agreement with the member regarding the behavior;

(ii) Advise the member that the MCE will provide, and the member shall be required to participate in individual education, disability accommodation, counseling, or other interventions in an effort to resolve the behavior; and

(iii) Inform the member that their continued behavior may result in disenrollment from the MCE.

(C) In the event the interventions undertaken in accordance with subsections (4)(e)(B) of this rule do not ameliorate the member’s uncooperative or disruptive behavior, the MCE shall Contact the member’s care team, or develop a member focused care team if one does not already exist, to support the member in remediating their behavior. If needed, and with the consent of the member, the care team shall involve other appropriate individuals working with the member in the resolution within the laws governing confidentiality. The MCE shall facilitate cross functional care conferences that include the member, member focused care team, and other individuals chosen by the member with appropriate releases documented;

(D) In the event the member’s uncooperative or disruptive behavior continues after undertaking the efforts identified in subsections (4)(e)(C) of this rule, the MCE shall convene an interdisciplinary team that includes a mental health professional or behavioral specialist and other health care professionals who have the clinical expertise necessary for reviewing and assessing the member’s behavior, their behavioral history, and previous efforts undertaken to manage the member’s behavior, including those developed through the members care team and care conferences, in order to determine whether the member may be able to remediate their uncooperative or disruptive behavior through other reasonable clinical or social interventions.

(f) All efforts undertaken in connection with this section (4) of the rule, including, without limitation, all interventions, written and oral communications, training and education provided to the member and the member’s provider(s), as well as those persons who participated in any and all interventions, care teams, assessments and the like, shall be documented in the member’s MCE case file and as applicable, the provider shall document all efforts undertaken in the member’s medical record;

(g) If, after undertaking all efforts identified in subsection (e) of this rule, the member’s disruptive or uncooperative behavior cannot be managed sufficiently in order for a provider to provide the services the member requires, the MCE may submit to its CCO AR on MCE letterhead a written request for disenrollment that complies with all of the following:

(A) Sets forth the reasons for the request for disenrollment, details the attempts at intervention and accommodations that were made, why those interventions and accommodations were not effective, and includes all written documentation required under subsection (4)(f) of this rule;

(B) Identifies, and provides documentation in support of the identification of, any special health care needs or disability the disruptive or uncooperative member may have and describes:

(i) The relationship the uncooperative or disruptive behavior may have, if any, to the member’s special health care needs or disability, which must be substantiated by a provider with the appropriate credentials and expertise in the member’s special health care needs or disability; and

(ii) Why the MCE has concluded the member’s disruptive or uncooperative behavior is not a consequence of the member’s special health care needs or disability.

(C) States whether the member’s uncooperative or disruptive behavior poses a direct threat to the health or safety of others;

(D) Identifies the documentation that supports the MCE’s rationale for concluding that the member’s continued enrollment in the MCE seriously impairs the MCE’s ability to furnish services to either the member who has engaged in the uncooperative or disruptive behavior or the MCE’s other members;

(E) Provides written documentation of CMS’ approval for disenrollment of the member when the member is also enrolled in the CCO’s Medicare Advantage plan;

(F) Furnishes all other information and documentation requested by the MCE’s CCO AR.

(h) If a Primary Care Provider (PCP) terminates the provider/patient relationship during the period of time the CCO is undertaking the efforts described in section (4) of this rule, the CCO shall, prior to submitting a request for disenrollment, attempt to locate another participating PCP who will accept the member as their patient. If needed, the CCO shall obtain an authorization for release of information from the member in order to share the information necessary for a new PCP to evaluate whether they can treat the member. All terminations of provider/patient relationships shall be consistent with the CCO’s OHP policies, the CCO or PCP’s policies for commercial members, and applicable disability discrimination laws.

(5) MCE Disenrollment Requests: Credible Threats of Violence.

(a) MCEs have the right to request an exception to the MCE initiated disenrollment requirements outlined in section (4) of this rule when a member has committed an act of, or made a credible threat of, physical violence directed at a health care provider, the provider’s staff, other patients, or the MCE staff, so that it seriously impairs the MCE’s ability to furnish services to either this particular member or other members;

(b) For purposes of this rule, a “credible threat” means that there is a significant risk that the member may cause grievous physical injury (including but not limited to death) in the near future, and that risk cannot be eliminated by a modification of policies, practices, or procedures;

(c) MCEs shall require their providers to notify both the MCE and law enforcement immediately when a member has acted violently or makes a credible threat of physical violence:

(A) The notification may be made to the MCE by telephone provided that such notice is followed by written notice to the MCE;

(B) Notice under subsection (5)(c) of this rule shall describe the circumstances surrounding the act or credible threat of violence and the actions taken by the provider as a result;

(C) MCEs shall require their providers to document the incident in the member’s medical record and the MCE shall document the provider’s notice in the member’s case file.

(d) The MCE shall notify the member’s care team of the act or credible threat of violence. The MCE shall involve the member’s care team and, within the laws governing confidentiality, other appropriate individuals which may include, without limitation, a mental health professional or behavioral specialist and other health care professionals who have the clinical expertise necessary for reviewing and assessing the member’s behavior to develop a plan to contact and provide support to the member in remediating the member’s violent behavior;

(e) The MCE and the care team shall make, and document all attempts at contacting and actual contacts with the member regarding the act or credible threat of violence;

(f) If the MCE determines the member does not pose an imminent and credible threat to others, the MCE shall undertake the efforts and processes listed in section (4) of this rule prior to making any request for disenrollment;

(g) If the MCE determines the member does pose an imminent and credible threat to others and cannot be remediated, as determined by the persons identified in subsection (5)(d) of this rule, by following the process set forth in section (4) of this rule, the MCE shall have the right to request the member’s disenrollment. The MCE’s disenrollment request shall comply with all of the requirements set forth in section (4)(g) of this rule and shall also comply with all additional requirements as follows:

(A) Include an explanation of why the MCE believes the exception to following the process explained in section (4) of this rule is necessary as it relates to an act of, or credible threat of, physical violence; and

(B) In addition to all other documentation required to be submitted under section (4) of this rule, the request must also include a copy of the police report or case number. If a police report or case number is not available, the MCE shall submit a copy of the provider’s entry in the member’s medical record, which must be signed by the provider, or a copy of the MCE’s entry into the member’s case file signed by the applicable MCE personnel, or both, that documents the report to law enforcement or any other reasonable evidence.

(6) Approval or Denials of MCE Requests for Disenrollment Due to Uncooperative or Disruptive Behavior, Acts of Violence, or Credible Threats of Violence.

(a) MCE requests made without all documentation, including CCO AR requests for additional or clarifying information, required under sections (4) and (5) of this rule shall be denied:

(A) When there is insufficient documentation submitted with a request for disenrollment, the CCO AR shall notify the MCE of the denial within two (2) business days of the initial request;

(B) MCEs may submit a new request for disenrollment once all required documentation is completed and available to be provided to the CCO AR.

(b) After receipt of a complete MCE request for disenrollment, the request shall be evaluated by the MCE’s CCO AR and relevant subject matter experts, including those with licensure or certification, as well as expertise appropriate to the circumstances identified in the request for disenrollment (disenrollment review team);

(c) The CCO AR shall document the review, recommendations, and rational with relevant regulatory or clinical criteria made by the disenrollment review team:

(A) The CCO AR shall provide the documentation and recommendations made by the disenrollment review team to Authority’s management for a decision regarding disenrollment of the affected member;

(B) The documentation provided to Authority management by the CCO AR shall also include the name of all disenrollment review team members, their respective areas of expertise, licensure or certification, or both;

(C) The decision, and all individuals involved in making the decision to approve or deny an MCE request for disenrollment under section (6) of this rule shall be documented in the affected member’s case file maintained by the Authority.

(d) The CCO AR shall provide written notice on Authority letterhead to the MCE of the Authority’s decision to approve or deny the MCE’s request for disenrollment. The CCO AR shall provide copies of the notice to the MCE CEO, MCE COO, and the Authority Medicaid Director:

(A) All notices of disenrollment approvals and denials shall include the reason for the decision along with applicable, supporting regulatory or clinical criteria, or both, and identify the subject matter expertise and credentials of the disenrollment review team. However, the names of the individuals on the disenrollment review team shall not be included in the notice;

(B) When there is sufficient documentation for the CCO AR to convene a disenrollment review team, the notice of approval or disapproval of the request for disenrollment shall be made by the Authority within fifteen (15) business days of receipt of the request for disenrollment.

(e) The CCO AR shall provide the affected member with written notice of their disenrollment within five (5) business days after the Authority has approved the MCE’s request for disenrollment. A copy of the member notice shall be sent to the MCE, which the MCE shall distribute to the member’s care team. A copy of the member notice shall be placed in the member’s case file maintained by the Authority. The notice of disenrollment provided to the member shall include all of the following information:

(A) The disenrollment date;

(B) The reason for disenrollment;

(D) All applicable statutory and regulatory support for the decisions made and the member’s rights. A copy of the member’s notice shall be included in the Authority’s record of the request and provided to the MCE for distribution the member’s care team.

(f) The date of disenrollment shall be effective ten calendar days after the date of the member’s disenrollment notice, unless:

(A) The member files a grievance or otherwise requests a hearing, in which case disenrollment is tolled pending the outcome of any and all final administrative processes. Upon final decision by an administrative law judge to uphold the Authority’s decision to grant disenrollment, or if the member chooses not to appeal any grievance that results in upholding the approval of disenrollment, the member’s disenrollment shall become effective immediately upon such decisions; or

(B) In cases where the member had a CCO aligned Medicare Advantage plan the date of disenrollment from the MCE shall be the same date as the disenrollment from the MCE aligned Medicare Advantage Plan approved by CMS.

(7) Enrollment for Authority Approved Disenrollment.

(a) When circumstance permit, the CCO AR shall enroll a member disenrolled under sections (4) or (5) of this rule into another MCE that is contracted for a service area that includes the member’s residence; or

(b) When circumstances permit, and there are multiple MCE’s contracted for the service area that includes the member’s residence, the CCO AR shall coordinate with the member’s care team to identify an appropriate MCE; or

(c) When no alternative MCE is available in service area that includes the member’s residence, the CCO AR shall place an enrollment exemption for the appropriate MCE CCOA, CCOB, CCOE, CCOF, and CCOG plans and place the member on Open Card for a twelve (12) month period, after which the CCO AR shall reevaluate enrollment options for the member.

(8) Unless specified otherwise in these rules, or in the Authority notification of disenrollment to the MCE, all disenrollments are effective the end of the month the Authority approves the disenrollment:

(a) If the member is no longer eligible for OHP, the effective date of disenrollment shall be the date specified by the Authority;

(b) If the member dies, the last date of enrollment shall be the date of the member’s death.

(9) Transfers of 500 or more members.

(a) As specified in ORS 414.611, the Authority may approve the transfer of 500 or more members from one MCE to another MCE if:

(A) The member’s provider has contracted with the receiving MCE and the provider has stopped accepting patients from the MCE from which the member is being transferred, or has terminated providing services to members who are enrolled with the MCE from which the member is being transferred;

(B) Members are offered the choice of remaining enrolled in the transferring MCE; and

(b) The transfer shall become effective the date on which the provider’s contract with their current MCE terminates or otherwise expires, or on another date approved by the Authority;

(A) The Authority has evaluated the receiving MCE and determined that the receiving MCE meets criteria established by the Authority as stated in OAR 410-141-3705 including, but not limited to, ensuring that the MCE maintains a network of providers sufficient in numbers, areas of practice, and geographically distributed in a manner to ensure that the health services provided under the contract are reasonably accessible to members; and

(B) The Authority has provided notice of a transfer to members affected by the transfer at least ninety (90) calendar days before the scheduled date of the transfer.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 90-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3815 CCO Enrollment for Temporary Out-of-Area Behavioral Health Treatment Services

(1) The Authority has determined that, to the maximum extent possible, all individuals shall be enrolled at the next available enrollment date following eligibility, redetermination, or upon review by the Authority. This rule implements and further describes how the Authority administers its authority under OAR 410-141-3805 and OAR 410-141-3810 for purposes of making enrollment decisions for adult and young adult individuals, 14 through and including 17 years of age, receiving temporary out-of-area behavioral health treatment services:

(a) For program placements in Child Welfare, Behavioral Rehabilitative Services, Oregon Youth Authority, and Psychiatric Residential Treatment Services, see OAR 410-141-3800 for program-specific rules;

(b) For program placements in Secure Children’s In-Patient (SCIP) and Secure Adolescent In-Patient (SAIP), CCOs shall work with the Authority in managing admissions and discharges;

(c) The member shall remain enrolled with the CCO for delivery of SCIP and SAIP services. The CCO shall bear care coordination responsibility for the entire length of stay, including admission, determination, and planning.

(2) Specific to residential settings specializing in the treatment of Substance Use Disorders (SUD), if the individual is enrolled in a CCO or FFS on the same day the individual is admitted to the residential treatment services, the CCO or FFS shall be responsible for the covered services during that placement even if the location of the facility is outside of the CCO’s service area. Upon discharge, FFS members shall, upon the next available enrollment date, enroll with the CCO that is contracted for their residential service area.

(3) Home CCO assignment is based on the member’s residence. Home CCO enrollment for temporary out-of-area placement shall:

(a) Meet Oregon residency requirements defined in OAR 410-200-0200;

(b) Comply with the CCO enrollment rules specified in OAR 410-141-3805;

(c) Be based on most recent permanent residency and related CCO enrollment history prior to temporary placement. If the client has no enrollment history, new enrollment shall reflect most recent permanent residence prior to hospital, institutional, and residential placement; and

(d) Be consistent with OAR 410-141-3810 when the client exercises recipient choice, where the client is able to actively participate in their own recovery and direct their own care. If the client is unable to designate county of residence, as indicated in OAR 410-200-0200, the Authority shall designate the Home CCO as the geographic location of the client at the most recent residency and CCO enrollment prior to hospitalization.

(4) Home CCO enrollment policy for State Hospital discharges shall be implemented as follows:

(a) Upon State Hospital discharge, the State Hospital Benefit Coordination Unit shall consult and coordinate with the Home CCO for client placement;

(b) Beginning in Contract year 2023 (or later if specified by the Authority), if the client is enrolled in a CCO at the time of the acute care admission to the State Hospital when a bed becomes available, the CCO shall be responsible for the covered services during that placement even if the location of the facility is outside of the CCO’s service area. The CCO’s responsibility shall be in accordance with a risk sharing agreement to be entered into between the CCO and the State Hospital, in a form required by the Authority. The individual is presumed to continue to be enrolled in the CCO with which the individual was most recently enrolled.

(5) For new and existing temporary residential placements, CCOs shall coordinate all behavioral health care and needs including, but not limited to, medication assisted treatment, routine non-emergent physical health care, oral, and transportation when within the scope of the CCO’s contract, including when member’s temporary placements are outside the CCO service area. CCO’s shall coordinate care for members receiving behavioral health treatment while in temporary placement and discharge planning for the return to the Home CCO. Additionally, CCO’s shall coordinate all care for accompanying dependent members.

(6) Enrollment shall follow the Home CCO enrollment policy outlined in this rule, except when:

(a) The Home CCO enrollment hinders access to care or puts the client at potential harm, or the Home CCO is unable to provide needed unique services, a change in enrollment may be requested for the member to a CCO serving the service area of the temporary out-of-area placement; or

(b) Home CCO enrollment may create a continuity of care concern, as specified in OAR 410-141-3810. If a continuity interruption to a client’s care is indicated, the Authority shall align enrollment with the care and claims history.

(7) Pursuant to OAR 410-141-3810, if the Authority determines that an individual was disenrolled for reasons not consistent with these rules, the Authority shall re-enroll the individual with the appropriate CCO and assign an enrollment date that provides for continuous CCO coverage with the appropriate CCO. If the individual was enrolled in a different CCO in error, the Authority shall disenroll the individual from the incorrect CCO and recoup the capitation payments, pursuant to OAR 410-120-1395. Re-enrollment to the correct CCO shall occur as specified in OAR 410-141-3805.

(8) For consideration of disenrollment decisions other than specified in this rule, OAR 410-141-3810 shall apply. If the Authority determines that disenrollment should occur, the CCO shall continue to provide covered services until the disenrollment date established by the Authority, pursuant to OAR 410-141-3860. This shall provide for an adequate transition to the next responsible CCO.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.610 - 414.685
Statutes/Other Implemented: ORS 413.042 & ORS 414.610 - 414.685
DMAP 90-2023, amend filed 12/21/2023, effective 01/01/2024
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3820 Covered Services

(1) General standard. The OHP Benefit Package includes treatments and health services which pair together with a condition on the same line of the Health Evidence Review Commission (HERC) Prioritized List of Health Services adopted under OAR 410-141-3830, to the extent that such line appears in the funded portion of the Prioritized List of Health Services. Coverage of these services is included in the benefit package when provided as specified in any relevant Statements of Intent and Guideline Notes of the Prioritized List of Health Services. The Benefit Package also covers the additional services described in this rule.

(a) As used in OAR 410-141-3820 and OAR 410-141-3825, the word “health services” has the meaning given in ORS 414.025(13);

(b) Services are covered with respect to an individual member only when the services are medically necessary and medically or dentally appropriate as defined in OAR 410-120-0000 and at the time they are provided, except that services shall also meet the prudent layperson standard defined in ORS 743A.012;

(c) HRSN Services are covered with respect to an individual member only when the Member belongs to an HRSN Covered Population and meets other service-specific eligibility criteria as defined in OAR 410-120-0000, OAR 410-120-2000, and OAR 410-120-2005;

(d) Benefit Package coverage of prescription drugs is discussed in OAR 410-141-3855;

(e) The Benefit Package is subject to the exclusions and limitations described in OAR 410-141-3825.

(2) MCE service offerings:

(a) MCEs shall offer their members, at a minimum:

(A) The physical, behavioral and/or oral health services covered under the member's benefit package, as appropriate for the MCE's mandatory scope of services; and

(B) Any additional services required in OAR chapter 410, or in the MCE contract.

(b) CCOs shall coordinate physical health, behavioral health, oral health care benefits, and HRSN benefits;

(A) OHP Benefit Package services except for Medicaid-funded long-term care, services, and supports; and

(B) Secondary payment for services covered by Medicare but not otherwise covered under the Oregon Health Plan as specified in OAR 410-141-3565 and specific to benefit packages in OAR 410-120-1210.

(3) Diagnostic services. Diagnostic services that are medically or dentally appropriate and medically necessary to diagnose the member's presenting condition (signs and symptoms) or guide management of a member's condition, regardless of whether the condition appears above or below the funded line on the Prioritized List of Health Services. Coverage of diagnostic services is subject to any applicable Diagnostic Guidelines on the Prioritized List of Health Services.

(4) Comfort care. Comfort care is a covered service for a member with a terminal illness.

(5) Preventive services. Preventive Services are included in the OHP benefit package as described in the funded portion of the Prioritized List of Health Services, as specified in related guideline notes. These services include, but are not limited to, periodic medical and dental exams based on age, sex, and other risk factors; screening tests; immunizations; and counseling regarding behavioral risk factors.

(6) Ancillary services. Ancillary services are covered subject to the service limitations of the Oregon Health Plan (OHP) program rules when:

(a) The services are medically necessary and medically or dentally appropriate in order to provide a funded service; or

(b) The provision of ancillary services shall enable the member to retain or attain the capability for independence or self-care.

(c) Coverage of ancillary services is subject to any applicable Ancillary Guidelines on the Prioritized List of Health Services.

(7) Telehealth Services. Telehealth services must be provided in compliance with OAR 410-120-1990.

(8) SUD services. The provision of SUD services shall comply with OAR 410-141-3545.

(9) Services necessary for compliance with the requirements for parity in mental health and substance use disorder benefits in 42 CFR part 438, subpart k.

(10) Services necessary for compliance with the requirements for Early and Periodic Screening, Diagnosis and Treatment as specified in the Oregon Health Plan 1115 Demonstration Project (waiver) and meeting requirements for individualized determination of medical necessity as specified in OAR 410-151-0002.

(11) Services necessary for compliance with the requirements for HRSN Services (as described in Oregon’s Medicaid 1115 Waiver for 2022-2027) and meeting requirements for individualized determination of Service authorization as specified in OAR 410-141-3835.

(12) Services necessary for compliance with the requirements for Reentry FCAA Services for Members who are FCAA-Covered Youth. Eligibility criteria and service requirements for Reentry FCAA Services are described in OAR 410-155-0000 and OAR 410-155-0010.

(13) Coverage of services for unfunded conditions based on effect on funded comorbid conditions:

(a) The OHP Benefit Package includes coverage in addition to that available under subsection (1). Specifically, it includes coverage of certain medically necessary and appropriate services for conditions which appear below the funding line in the Prioritized List of Health Services if it can be shown that:

(A) The member has a funded condition for which documented clinical evidence shows that the funded treatments are not working or are contraindicated; and

(B) The member concurrently has a medically related unfunded condition that is causing or exacerbating the funded condition; and

(C) Treating the unfunded medically related condition may significantly improve the outcome of treating the funded condition.

(b) Services that are expressly excluded from coverage as described in OAR 410-141-3825 are not subject to consideration for coverage under subsection (11);

(c) Any co-morbid conditions or disability shall be represented by an ICD diagnosis code or, when the condition is a mental disorder, represented by a DSM diagnosis;

(d) In order for the services to be covered, there shall be a medical determination and finding by the Authority (for fee-for-service OHP clients) or by the MCE (for MCE members) that the terms of subsection (a) of this rule have been met based upon the applicable:

(A) Treating health care provider opinion;

(B) Medical research; and

(14) Ensuring that all coverage options are considered:

(a) When a provider receives a denial for a non-covered service for any member, especially a member with a disability or with a co-morbid condition, the provider shall determine whether there may be a medically appropriate covered service to address the member's condition or clinical situation, before declining to provide the non-covered service. The provider's determination shall include consideration of whether a service for an unfunded condition may improve a funded comorbid condition under subsection (11);

(b) If a member seeks, or is recommended, a non-covered service, providers shall ensure that the member is informed of:

(A) Clinically appropriate treatment that may exist, whether covered or not;

(B) Community resources that may be willing to provide the relevant non-covered service;

(c) Before an MCE denies coverage for an unfunded service for any member, especially a member with a disability or with a co-morbid condition, the MCE shall determine whether the member has a funded condition or condition/treatment pair that may entitle the member to coverage under the program.

(15) Assistance to providers. The Authority shall maintain a telephone information line for the purpose of assisting practitioners in determining coverage under the OHP Benefit Package. The telephone information line shall be staffed by registered nurses who shall be available during regular business hours. If an emergency need arises outside of regular business hours, the Authority shall make a retrospective determination under this section, provided the Authority is notified of the emergency situation during the next business day. If the Authority denies a requested service, the Authority shall provide written notification and a notice of the right to an administrative hearing to both the OHP member and the treating physician within five (5) working days of making the decision.

(16) Ad hoc coverage determinations.

(a) When a member requests a hearing pertaining to a funded condition and a funded or unfunded treatment that does not pair on the HERC Prioritized List of Health Services, and the treatment is not included in the excluded services guideline notes of the prioritized list, before the hearing the Division shall determine if the requested treatment is appropriate and necessary for the member.

(b) For treatments determined to be appropriate and necessary under subsection (a), the Division determines whether the HERC has considered the funded condition/treatment pair for inclusion on the Prioritized List within the last five (5) years. If the HERC has not considered the pair for inclusion within the last five (5) years, the Division shall make an ad hoc coverage determination in consultation with the HERC.

(c) For treatments determined to not be appropriate and necessary under (a) in this section the hearing process shall proceed.

(17) General anesthesia for dental procedures. General anesthesia for dental procedures that are medically necessary and medically or dentally appropriate to be performed in a hospital or ambulatory surgical setting may be used only for those members as detailed in OAR 410-123-1490.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065, 414.572, 414.605, 414.665 & 414.719
DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 39-2025, amend filed 04/25/2025, effective 04/25/2025
DMAP 151-2024, minor correction filed 12/30/2024, effective 12/30/2024
DMAP 130-2024, amend filed 10/24/2024, effective 11/01/2024
DMAP 80-2024, minor correction filed 03/22/2024, effective 03/22/2024
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3825 Excluded Services and Limitations

(1) The following services are excluded from the Oregon Health Plan Benefit Package, except as otherwise provided in OAR 410-141-3820:

(a) Any service identified for exclusion in OAR 410-120-1200 or 410-120-1210;

(b) Any service identified in applicable provider guides as a non-covered service, unless the service is identified as specifically covered under the OHP administrative rules;

(c) Any service that is not a funded service, even if it is provided for a condition that appears in the funded region of the list, or if the service in question is a funded service when provided for an unfunded diagnosis on the prioritized list;

(d) Services that, when provided, are funded services on the Prioritized List of Health Services, but which are otherwise excluded from the OHP Benefit Package for the client in question;

(e) Diagnostic services not reasonably necessary to establish a diagnosis or guide management or treatment decisions, regardless of whether the condition or treatment in question is a funded service;

(f) Services requested by OHP clients in an emergency care setting that do not satisfy the coverage rules in OAR 410-141-3820;

(g) Services provided to an OHP client outside the territorial limits of the United States, except in those instances in which the country operates a Medical Assistance (Title XIX) program;

(h) Services other than inpatient care provided to an OHP client who is in the custody of a law enforcement agency or an inmate of a non-medical public institution, including juveniles in detention facilities, per OAR 410-141-3810;

(i) Services received while the client is outside the MCE's service area, except for services that were:

(A) Ordered or referred by the client’s primary care provider; or

(B) Urgent or emergency services; or

(D) This exclusion does not apply if the client was outside the MCE's service area because of circumstances beyond the client’s control. Factors to be considered include but are not limited to death of a family member outside of the MCE’s service area. If the client successfully establishes this fact, including during the grievance and appeal process, then this exclusion does not apply.

(2) The following services are limited or restricted:

(a) Any service which exceeds those that are medically appropriate and necessary to provide reasonable diagnosis and treatment; enable the OHP client to attain or retain the capability for independence or self-care; or screen for preventable disease or disease exacerbation. This limitation includes services that, upon medical review, could not reasonably have been expected to provide more than minimal benefit in treatment or information to aid in a diagnosis;

(b) Diagnostic services not reasonably required to diagnose a presenting problem, whether the resulting diagnosis and indicated treatment are on the currently funded lines under the OHP Prioritized List of Health Services;

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3826 Responsibility for Particular Covered Services Based on Plan Type

(1) Coordinated Care Organization (CCO) responsibility for particular Covered Services, as that responsibility is described in the CCO contract, is determined by the member's plan type, as follows:

(a) Universally Offered Newborn Nurse Home Visiting Program, commonly known as Family Connects Oregon (FCO): FCO is governed by ORS 433.301 and described in OAR Chapter 333, Division 6;

(A) The CCO is responsible for care coordination for FCO services for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB);

(B) The Oregon Health Authority's (Authority) fee-for-service (FFS) program is responsible for FCO services for all other plan types that include physical health services.

(b) Out-of-Hospital Birth, commonly known as Planned Community Birth (PCB): PCB is described in OAR 410-141-3846;

(A) The CCO is responsible for the components of PCB specified in the CCO contract for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB);

(B) The Authority’s FFS program is responsible for PCB for all other plan types that include physical health services. The FFS program is also responsible for the components of PCB not specified as the CCO's responsibility in the contract for members for whom the CCO is responsible for physical health services.

(c) Health-Related Social Needs (HRSN) Services: HRSN Services are authorized by the Oregon Health Plan 1115 Demonstration Project for 2022-2027, commonly known as the State 1115 Waiver, approved by the Centers for Medicare and Medicaid Services;

(A) The CCO is responsible for all HRSN Services for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB), regardless of whether a particular HRSN Service is related to the member's physical health condition or needs;

(B) OHA's FFS program is responsible for all HRSN Services for an eligible member if the FFS program is responsible for the member's physical health services, regardless of whether a particular HRSN Service is related to the member's physical health condition or needs.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.591 & 414.631
DMAP 36-2024, adopt filed 01/25/2024, effective 02/01/2024

Or. Admin. R. 410-141-3830 Prioritized List of Health Services

(1) The Health Evidence Review Commission (HERC) Prioritized List of Health Services (Prioritized List) is the listing of physical and behavioral health services generated and maintained by HERC. The Authority may apply criteria listed in Statements of Intent and Practice Guidelines (Guideline Notes, Ancillary Guideline Notes, Diagnostic Guideline Notes and Excluded Services Guideline Notes) from the Prioritized List to codes and lines not explicitly specified in that guideline note and to services such as diagnostic, ancillary and excluded irrespective of their inclusion on the lines of the Prioritized List. The HERC maintains the most current list on their website: https://www.oregon.gov/OHA/HPA/DSI-HERC/Pages/Prioritized-List.aspx. For a hard copy, contact the Division within the Oregon Health Authority (Authority).

(2) This rule, effective February 1, 2026, incorporates by reference the February 1, 2026 Prioritized List, funded through line 470 and including all line items, diagnosis and treatment codes, guideline notes, statements of intent, coding specifications and annotations. This Prioritized List dated February 1, 2026 supersedes the January 1, 2026 Prioritized List for services provided after February 1, 2026, and includes interim modifications reported as required under ORS 414.690(7) and (8).

History

Statutory/Other Authority: ORS 414.065 & 413.042
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 32-2026, amend filed 07/27/2026, effective 07/27/2026
DMAP 4-2026, temporary amend filed 01/28/2026, effective 02/01/2026 through 07/30/2026
DMAP 91-2025, amend filed 12/19/2025, effective 01/01/2026
DMAP 72-2025, amend filed 09/26/2025, effective 10/01/2025
DMAP 147-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 122-2024, temporary amend filed 09/25/2024, effective 10/01/2024 through 03/29/2025
DMAP 76-2024, amend filed 03/15/2024, effective 03/22/2024
DMAP 88-2023, temporary amend filed 12/19/2023, effective 01/01/2024 through 06/28/2024
DMAP 80-2023, amend filed 09/30/2023, effective 10/01/2023
DMAP 26-2023, amend filed 04/11/2023, effective 04/11/2023
DMAP 1-2023, temporary amend filed 01/25/2023, effective 02/01/2023 through 07/30/2023
DMAP 88-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 81-2022, amend filed 10/04/2022, effective 10/04/2022
DMAP 72-2022, temporary amend filed 08/25/2022, effective 10/01/2022 through 10/11/2022
DMAP 56-2022, temporary amend filed 06/17/2022, effective 06/17/2022 through 10/11/2022
DMAP 51-2022, temporary amend filed 04/27/2022, effective 04/27/2022 through 10/11/2022
DMAP 47-2022, temporary amend filed 04/15/2022, effective 04/15/2022 through 10/11/2022
DMAP 42-2021, temporary amend filed 09/20/2021, effective 10/01/2021 through 03/29/2022
DMAP 13-2021, amend filed 03/25/2021, effective 03/29/2021
DMAP 3-2021, temporary amend filed 01/28/2021, effective 02/01/2021 through 03/29/2021
DMAP 70-2020, temporary amend filed 12/30/2020, effective 01/01/2021 through 03/29/2021
DMAP 51-2020, temporary amend filed 09/28/2020, effective 10/01/2020 through 03/29/2021
DMAP 43-2020, amend filed 09/01/2020, effective 09/10/2020
DMAP 40-2020, temporary amend filed 08/25/2020, effective 08/25/2020 through 09/10/2020
DMAP 8-2020, temporary amend filed 03/15/2020, effective 03/15/2020 through 09/10/2020
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3835 CCO Service Authorization

(1) Coverage of services is outlined by CCO contract and Oregon Health Plan (OHP) benefits coverage in OAR 410-120-1210 and OAR 410-120-1160.

(2) A member may access urgent and emergency services 24 hours a day, seven (7) days a week without prior authorization.

(3) The CCO must not require a member to obtain the approval of a primary care physician to gain access to behavioral assessment and evaluation services. A member may self-refer to assessment, evaluation, and behavioral health services from the Provider Network. Members may obtain primary care services in a behavioral health setting, and behavioral health services in a primary care setting without authorization.

(4) A member may access the following outpatient services from within the CCO's Provider Network, without Prior Authorization, including but not limited to:

(a) “Assertive Community Treatment” as defined in OAR 309-019-0105, “Enhanced Care Services” as defined in OAR 309-019-0105, “Enhanced Care Outreach Services” as defined in OAR 309-019-0105, “Wraparound” as defined in OAR 309-019-0105, “Behavior Supports, Crisis Care” as defined in OAR 309-019-0105, “Respite Care” as defined in OAR 309-019-0105, and “Intensive Outpatient Services and Supports” as defined in OAR 309-019-0105;

(b) Behavioral Health Peer Delivered Services as defined in OAR 309-019-0125 from within the CCO's Provider Network;

(c) Medication-Assisted Treatment for Substance Use Disorders as defined in OAR 309-019-0105, including opioid and opiate use disorders. Prior authorization may only be required:

(A) For a medication approved by the United States Food and Drug Administration after January 1, 2024; or

(B) For a brand name drug for medication-assisted treatment if a generic equivalent is available to substitute for the prescribed brand name drug. For the purposes of this rule, a different formulation of the medication is not a generic equivalent.

(d) Drugs prescribed for the prevention or treatment of human immunodeficiency virus (HIV):

(A) When the drug has been approved by the United States Food and Drug Administration for the prevention or treatment of HIV and determined to be medically necessary by the prescribing provider;

(B) Step therapy must also not be required for these drugs.

(5) Contractors must permit out-of-network IHCPs to refer a CCO-enrolled American Indian/Alaska Native to a network provider for covered services as required by 42 CFR 438.14(b)(6).

(6) The CCO shall ensure the services are furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid and as described in ORS chapter 414 and applicable administrative rules, based on the Prioritized List of Health Services and OAR 410-120-1160, 410-120-1210, and 410-141-3830.

(7) CCOs must not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary.

(8) CCOs shall observe required timelines for standard authorizations, expedited authorizations, and specific OHP rule requirements for authorizations for services, including but not limited to residential treatment or substance use disorder treatment services and requirements for advance notice set forth in OAR 410-141-3885. CCOs shall observe required timely access to service timelines as indicated in OAR 410-141-3515.

(9) CCOs may place appropriate limits on a service authorization for Covered Services based on Medical Necessity and Medical Appropriateness as defined in OAR 410-120-0000, or for utilization control provided that the CCO:

(a) Ensures the services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished;

(b) Authorizes the services supporting individuals with ongoing or chronic conditions or those conditions requiring long-term services and supports in a manner that reflects the member's ongoing need for the services and supports;

(c) Provides family planning services in a manner that protects and enables the member's freedom to choose the method of family planning to be used consistent with 42 CFR § 441.20 and the member's free choice of provider consistent with 42 USC § 1396a(a)(23)(B) and 42 CFR § 431.51; and

(d) Ensures compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, delay, or discontinue medically necessary services to any member.

(10) CCOs must not use quality of life in general measures in establishing utilization controls (e.g., prior authorization) or otherwise making benefit determinations per OAR 410-120-1320.

(11) Once a member is determined to be eligible for health-related social needs (HRSN) Services as outlined in OAR 410-120-2000, OAR 410-120-2005, and OAR 410-120-2015, CCOs may place appropriate limits on a service authorization for HRSN Services or for utilization control provided the CCO:

(a) Ensures the HRSN Services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished;

(b) Authorizes the HRSN Services supporting individuals with ongoing or chronic conditions or those conditions requiring long-term services and supports in a manner that reflects the member's ongoing need for the services and supports; and

(c) Ensures compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, delay, or discontinue the delivery of HRSN Services to any member who is eligible for those services under OAR 410-120-2000, OAR 410-120-2005, and OAR 410-120-2015.

(12) For authorization of services:

(a) Each CCO shall follow the following timeframes for authorization requests other than for drug or HRSN services:

(A) For standard authorization requests for services not previously authorized and not for repairs of complex rehabilitation technology as defined in Section 2 of Enrolled SB 549 (2025), provide notice per paragraph (G) in this section as expeditiously as the member’s condition requires and no later than seven (7) calendar days following receipt of the request for service.

(B) For expedited authorization decisions, provide notice per paragraph (G) in this section as expeditiously as the member's health condition requires and no later than 72 hours after receipt of the request for service, which period of time shall be determined by the time and date stamp on the receipt of the request;

(C) If additional documentation is required to render a decision for requests in paragraphs (A) and (B), make one (1) attempt to obtain the information during the seven (7) calendar day standard review period or 72 hour expedited review period.

(D) An extension of up to 14 calendar days for a standard or expedited authorization decision in paragraph (A) or (B) is possible if the following applies:

(i) The member, the member's representative, or provider requests an extension; or

(ii) The CCO needs additional information to process the request, and the extension is in the member’s interest. If the Authority requests, the CCO will justify a need for the additional information and how the extension is in the member's interest.

(E) If a 14 calendar day extension has been justified, the CCO shall:

(i) Give written notice to the member of the reason for the extension;

(iii) Respond to the request for authorization per paragraph (G) in this section as expeditiously as the member's health or mental health condition requires, but no later than the expiration of the extension; and

(iii) If the reason for the extension is to obtain additional documentation, make two (2) attempts to obtain the information during the extended review period in addition to the attempt required in paragraph (C) for the initial review period. The total of three (3) attempts shall include the use of two (2) methods to obtain the information.

(F) For all prior authorization requests for repairs of complex rehabilitation technology as defined in Section 2 of Enrolled SB 549 (2025), provide notice per paragraph (G) in this section as expeditiously as the member’s condition requires and no later than 72 hours following receipt of the request for service. No extension shall be allowed.

(G) Responses to requests for prior authorization of services in paragraphs (A), (B), (E) and (F) in this section shall be in one of the following forms:

(i) A written, electronic or telephonic notice of the approval of the service as requested to the requesting provider; or

(ii) A written notice of adverse benefit determination per OAR 410-141-3885 to the requesting provider, the member and the member’s representative.

(b) Prior authorization requests for outpatient drugs, including a practitioner administered drug (PAD), shall be addressed by the CCOs as follows:

(A) Respond to requests for prior authorizations for outpatient drugs within 24 hours as described in 42 CFR 438.210(d)(3) and section 1927(d)(5) of the Social Security Act. This shall include one attempt within the first 24 hours to obtain additional necessary information if needed. An initial response shall include:

(i) A written, telephonic or electronic communication of approval of the drug as requested to the member, and prescribing practitioner, and when known to the CCO, the pharmacy; or

(ii) A written notice of adverse benefit determination of the drug per OAR 410-141-3885 to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the CCO, the pharmacy if the drug is denied or partially approved; or

(iii) A written, telephonic, or electronic request for additional documentation to the prescribing practitioner when the prior authorization request lacks the CCO's standard information collection tools such as prior authorization forms or other documentation necessary to render a decision; or

(iv) A written, telephonic, or electronic acknowledgment of receipt of the prior authorization request that gives an expected timeframe for a decision. An initial response indicating only acceptance of a request must not delay a decision to approve or deny the drug within 72 hours.

(B) The 72-hour window for a coverage decision begins with the initial date and time stamp of a prior authorization request for a drug;

(C) If the response is a request for additional documentation, the CCO shall identify and notify the prescribing practitioner of the documentation required to make a coverage decision and comply within the following timeframes:

(i) Upon receiving the CCO's completed prior authorization forms and required documentation, the CCO shall issue a decision as expeditiously as the member's health requires, but no later than 72 hours from the date and time stamp of the initial request for prior authorization as follows:

(I) If the drug is approved as requested, the CCO shall notify the member in writing and prescribing practitioner, and when known to the CCO, the pharmacy, telephonically, or electronically; or

(II) If the drug is denied or partially approved, the CCO shall issue a written notice of adverse benefit determination to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the CCO, the pharmacy.

(ii) If the requested additional documentation is not received within 72 hours from the date and time stamp of the initial request for prior authorization, the CCO shall issue a written notice of adverse benefit determination to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the CCO, the pharmacy.

(D) The CCO shall provide approved services as expeditiously as the member's health condition requires;

(E) If an emergency situation justifies the immediate medical need for the drug during this review process, an emergency supply of 72 hours or longer shall be made available until the CCO makes a coverage decision.

(d) For members with special health care needs as determined through an assessment requiring a course of treatment or regular care monitoring, each CCO shall have a mechanism in place to allow members to directly access a specialist (for example, through a standing referral or an approved number of visits) as appropriate for the member's condition and identified needs;

(e) Any service authorization decision not reached within the timeframes specified in this rule shall constitute a denial and becomes an adverse benefit determination. A notice of adverse benefit determination shall be issued on the date the timeframe expires;

(f) CCOs shall give the member written notice of any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested or when reducing a previously authorized service authorization. The notice shall meet the requirements of CFR § 438.404 and OAR 410-141-3885;

(g) The CCO and its subcontractors shall have and follow written policies and procedures to ensure consistent application of review criteria for service authorization requests including the following:

(A) For medical, behavioral, or oral health Covered Services:

(i) The CCO shall consult with the requesting provider for medical, behavioral, or oral health services when necessary:

(I) Requesting all the appropriate information to support decision making as early in the review process as possible; and

(II) Adding documentation in the authorization file on outreach methods and dates when additional information was requested from the requesting provider.

(ii) Decisions shall be made by an individual who has clinical expertise in addressing the member's medical, behavioral, or oral health needs or in consultation with a health care professional with clinical expertise in treating the member's condition or disease. This applies to decisions to:

(I) Deny a service authorization request;

(II) Reduce a previously authorized service request; or

(III) Authorize a service in an amount, duration, or scope that is less than requested.

(B) For HRSN Services, the CCO shall comply with OAR 410-120-2020.

(C) CCOs shall have written policies and procedures for processing prior authorization requests received from any provider. The policies and procedures shall specify timeframes for the following:

(i) Date and time stamping prior authorization requests when received;

(ii) Determining within a specific number of days from receipt whether a prior authorization request is valid or non-valid;

(iii) The specific number of days allowed for follow-up on pended prior authorization requests to obtain additional information;

(iv) The specific number of days following receipt of the additional information that an approval or denial shall be issued;

(v) Providing services after office hours and on weekends that require prior authorization.

(D) A CCO shall make a determination on at least 95 percent of valid prior authorization requests within two (2) business days of receipt of a prior authorization or reauthorization request related to:

(i) Drugs;

(ii) Alcohol;

(iii) Drug services; or

(iv) Care required while in a skilled nursing facility.

(13) Report to the Authority annually requests for prior authorization. The report shall include:

(a) The number of requests received;

(b) The number of requests that were initially denied and the reasons for the denials, including, but not limited to, lack of medical necessity or failure to provide additional clinical information requested by the insurer;

(d) The number of denials that were reversed by internal appeals or external reviews.

History

Statutory/Other Authority: ORS 413.042, 414.065, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.065 & 414.570-414.686
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 40-2025, amend filed 04/25/2025, effective 05/01/2025
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 35-2024, amend filed 01/22/2024, effective 01/22/2024
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3840 Emergency and Urgent Care Services

(1) CCOs shall have written policies, procedures, and monitoring systems that ensure the provision of appropriate urgent, emergency, and triage services 24-hours a day, 7-days-a-week for all members. CCOs shall:

(a) Communicate these policies and procedures to participating providers;

(b) Regularly monitor participating providers' compliance with these policies and procedures; and

(c) Take any corrective action necessary to ensure compliance. CCOs shall document all monitoring and corrective action activities.

(2) CCOs shall have written policies, procedures, and monitoring processes to ensure that a provider provides a medically or orally appropriate response as indicated to urgent or emergency calls including but not limited to the following:

(a) Telephone or face-to-face evaluation of the member;

(b) Capacity to conduct the elements of an assessment to determine the necessary interventions to begin stabilization;

(d) Provision of services and referral needed to begin post-stabilization care or provide outreach services in the case of a member requiring behavioral health services, or a member who cannot be transported or is homebound;

(e) Provision for notifying a referral emergency room, when applicable, concerning the arriving member’s presenting problem, and whether or not the provider will meet the member at the emergency room; and

(f) Provision for notifying other providers that prior authorization is required for post-stabilization care in accordance with this rule.

(3) CCOs shall ensure the availability of an after-hours call-in system adequate to triage urgent care and emergency calls from members or a member’s long-term care provider or facility. The CCO representative shall return urgent calls appropriate to the member's condition but in no event more than 30 minutes after receipt. If information is not adequate to determine if the call is urgent, the CCO representative shall return the call within 60 minutes to fully assess the nature of the call. If information is adequate to determine that the call may be emergent in nature, the CCO shall return the call.

(4) If emergency room screening examination leads to a clinical determination by the examining provider that an actual emergency medical condition exists under the prudent layperson standard, the CCO must pay for all services required to stabilize the patient, except as otherwise provided in section (6) of this rule. The CCO may not require prior authorization for emergency services:

(a) The CCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard, turned out to be non-emergent;

(b) The CCO may not limit what constitutes an emergency medical condition based on lists of diagnoses or symptoms;

(c) The CCO may not deny a claim for emergency services merely because the PCP was not notified, or because the CCO was not timely billed for the service.

(5) When a member's PCP, designated provider, or other CCO representative instructs the member to seek emergency care, whether for physical, behavioral, or dental services, whether in or out of the network, the CCO shall pay for the screening examination and other medically appropriate services. Except as otherwise provided in section (6) of this rule, the CCO shall pay for post-stabilization care that was:

(a) Pre-authorized by the CCO;

(b) Not pre-authorized by the CCO if the CCO, or the on-call provider, failed to respond to a request for pre-authorization within one hour of the request, or the member could not contact the CCO or provider on call; or

(c) If the CCO and the treating provider cannot reach an agreement concerning the member's care and a CCO representative is not available for consultation, the CCO must give the treating provider the opportunity to consult with a CCO provider. The treating provider may continue with care of the member until a CCO provider is reached or one of the criteria is met.

(6) The CCO’s responsibility for post-stabilization care it has not authorized ends when:

(a) The participating provider with privileges at the treating hospital assumes responsibilities for the member's care;

(b) The participating provider assumes responsibility for the member's care through transfer;

(d) The member is discharged.

(7) CCOs shall have methods for tracking inappropriate use of urgent and emergency care and shall take action, including individual member counseling, to improve appropriate use of urgent and emergency care services:

(a) CCOs shall educate members about, and support them in, how to appropriately access care from emergency rooms, urgent care and walk-in clinics, non-traditional health care workers, and less intensive interventions other than their primary care home;

(b) CCOs shall apply and employ innovative strategies to decrease unnecessary hospital utilization.

(8) CCOs must limit charges to members for post-stabilization care services to an amount no greater than what the CCO would charge the member if he or she had obtained the services through the CCO. For purposes of cost sharing, post stabilization care services begin upon inpatient admission.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3845 Flexible Services

(1) The goals of Flexible Services are to promote the efficient use of resources and address members' social determinants of health to improve health outcomes, alleviate health disparities, and improve overall community well-being. Flexible Services are provided as a complement to covered health care services:

(a) Flexible Services may be provided at the member- or community-level, as defined below;

(b) CCOs have the flexibility to identify and provide Flexible Services beyond the list of examples in 45 CFR §§ 158.150, 158.151, as long as they satisfy the requirements of this rule;

(c) Flexible Services may be used to pay for non-covered health care services including physical health, mental health, behavioral health, oral health, and tribal-based services.

(2) To qualify as Flexible Services within the meaning of this rule, a service must meet the following requirements, consistent with 45 CFR § 158.150:

(a) The service must be designed to:

(A) Improve health quality;

(B) Increase the likelihood of desired health outcomes in a manner that is capable of being objectively measured and produce verifiable results and achievements;

(C) Be directed toward either individuals or segments of members, or provide health improvements to the population beyond those enrolled without additional costs for the non-members; and

(D) Be based on any of the following:

(i) Evidence-based medicine; or

(ii) Widely accepted best clinical practice; or

(iii) Criteria issued by accreditation bodies, recognized professional medical associations, government agencies, or other national health care quality organizations.

(b) The service must be primarily designed to achieve at least one of the following goals:

(A) Improve health outcomes compared to a baseline and reduce health disparities among specified populations;

(B) Prevent avoidable hospital readmissions through a comprehensive program for hospital discharge;

(D) Implement, promote, and increase wellness and health activities;

(E) Support expenditures related to health information technology and meaningful use requirements necessary to accomplish the activities above that are set forth in 45 CFR 158.151 that promote clinic community linkage and referral processes or support other activities as defined in 45 CFR 158.150.

(A) Those that are designed primarily to control or contain costs;

(B) Those that otherwise meet the definitions for quality improvement activities but that were paid for with grant money or other funding separate from revenue received through a CCO's contract;

(C) Those activities that may be billed or allocated by a provider for care delivery and that are, therefore, reimbursed as clinical services;

(D) Establishing or maintaining a claims adjudication system, including costs directly related to upgrades in health information technology that are designed primarily or solely to improve claims payment capabilities or to meet regulatory requirements for processing claims, including maintenance of ICD-10 codes sets adopted pursuant to the Health Insurance Portability and Accountability Act (HIPAA), 42 U.S.C. § 1320d-2, as amended;

(E) That portion of the activities of health care professional hotlines that do not meet the definition of activities that improve health quality;

(F) All retrospective and concurrent utilization review;

(G) Fraud prevention activities;

(H) The cost of developing and executing provider contracts and fees associated with establishing or managing a provider network, including fees paid to a vendor for the same reason;

(I) Provider credentialing;

(J) Costs associated with calculating and administering individual member incentives; and

(K) That portion of prospective utilization that does not meet the definition of activities that improve health quality.

(3) CCOs shall implement Policies and Procedures (P&Ps) for Flexible Services. These P&Ps shall be submitted within five (5) business days of the Authority’s request.

(a) Flexible Services P&Ps shall encourage transparency and provider and member engagement, reflect streamlined administrative processes that do not create unnecessary barriers, and provide for accountability;

(b) A CCO's Flexible Services spending at the community level shall promote alignment with the priorities identified in the CCO's community health improvement plan, and with any community-level Flexible Services spending priorities identified by the Authority;

(c) The P&Ps shall describe how Flexible Services spending decisions are made, including the role of the CAC and tribes in community-level Flexible Services spending decisions;

(d) CCOs must not limit the range of permissible Flexible Services by any means other than by enforcing the limits defined in this rule.

(4) Member-level Flexible Services are cost-effective services offered to an individual member as an adjunct to covered benefits. Member-level Flexible Services shall be consistent with the member's treatment plan as developed by the member's care team and agreed to by the CCO. The care team and the CCO shall work with the member and, as appropriate, the family of the member in determining the Flexible Services needed to supplement the member's care:

(a) CCOs shall provide members with a written notification of a refusal of a member-level Flexible Services request and shall copy any representative of the member and any provider who made or participated in the request on the member's behalf. The written notification shall inform the member and provider of the member's right to file a grievance in response to the outcome;

(b) A CCO's refusal to permit a member-level Flexible Services request is not an “adverse benefit determination” within the meaning of OAR 410-141-3875. CCOs shall have written procedures to acknowledge the receipt, disposition, and documentation of each grievance from members, which shall be modelled on the procedures specified in 42 CFR 438.402-408 and OAR 410-141-3835 through 3915.

(5) Community-level Flexible Services initiatives are community-level interventions that include, but are not necessarily limited to, members and are focused on improving population health and health care quality. CCOs shall designate a role for the community advisory council in community-level Flexible Services spending decisions.

(6) CCOs shall submit their financial reporting for Flexible Services as directed through the CCO contract and in compliance with 42 CFR 438.8 Medical Loss Ratio (MLR).

(7) Except as provided in section (4), members have no appeal or hearing rights in regard to a refusal of a request for Flexible Services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 101-2025, temporary amend filed 12/30/2025, effective 01/02/2026 through 06/30/2026
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3846 Palliative Care Program.

(1) Definitions.

(a) "Assessment" means procedures by which a qualified practitioner of the healing arts identifies strengths, weaknesses, problems, and needs to determine a member's need for palliative care services.

(b) "Palliative care interdisciplinary team (PCIDT)" means a team of individuals working together in a coordinated manner to provide palliative care services, which may include the family-patient unit. An interdisciplinary team is composed of the following core team members who are trained or certified in palliative care:

(A) A registered nurse;

(B) A social worker; and

(D) In addition to (a-c) above, the interdisciplinary team may include one or more of the following palliative care program personnel:

(i) Licensed practical nurse;

(ii) Certified nurse's aide;

(iii) Home health aide;

(iv) Hospice aide;

(v) Community health worker;

(vi) Occupational therapist;

(vii) Physical therapist;

(viii) Trained volunteer (faith or community based);

(ix) Spiritual care professional;

(x) Advanced practice clinicians; and

(xi) Licensed or credentialed mental health professionals including:

(I) Licensed psychiatrist;

(II) Licensed psychologist;

(III) Psychiatric nurse; and

(IV) Qualified Mental Health Professional.

(c) "Palliative care services" means comfort services that focus primarily on reduction or abatement of physical, emotional, social, functional deficiency and spiritual symptoms of serious illness.

(d) "Primary caregiver" means the person designated by the patient or the patient's representative to assume responsibility for care of the patient as needed. If the patient has no designated primary caregiver and is unable to designate one, the interdisciplinary team may designate a primary caregiver.

(e) "Portable Orders for Life-Sustaining Treatment (POLST)" means the formal written medical orders for life sustaining treatment signed by a physician, naturopathic physician, nurse practitioner or physician assistant that helps identify the types of medical treatment a patient shall receive during their palliative care.

(f) "Prognosis" means the probable outcome of a disease over a given period of time.

(g) "Residential care facility" has the meaning given that term in ORS 443.400.

(h) "Serious Illness" means a disease, injury, or other physical, cognitive or mental condition that is life-limiting.

(i) "Skilled nursing facility" has the meaning given that term in ORS 442.015.

(j) "Symptom management" means assessing and responding to the physical, emotional, social, functional and spiritual needs of the patient and their family.

(2) System of Care.

(a) A Coordinated Care Organization (CCO) shall maintain a network to provide a community or home-based Palliative care benefit for its members.

(b) A residential care facility or a skilled nursing facility is not subject to these rules for the Palliative Care Program established for CCOs in providing or arranging palliative care services for residents of the facilities.

(c) A provider of palliative care services under the program and a CCO shall determine the reimbursement paid for services by mutual agreement.

(3) Eligibility for the Palliative Care Program.

(a) A patient qualifies for palliative care services under the program if they:

(A) Have been diagnosed with a serious illness that has a negative impact on the patient's quality of life or the quality of life of their primary caregiver; and

(B) Palliative care is ordered by the patient’s primary care, specialty care or hospital-based provider.

(b) If Medicare or other insurance is available it must be billed before billing Medicaid.

(4) Plan of Care.

(a) A written plan of care must be established for eligible member electing palliative care and maintained for each patient eligible for palliative care services, and the care provided to a patient by the PCIDT must be provided in accordance with the plan of care.

(b) The plan of care is developed and updated at minimum every year or whenever there are significant changes in the patient's condition or patient's service choices, and as directed by the patient accessing palliative care services or the patient's representative, in collaboration with the members of the PCIDT.

(A) A comprehensive palliative care assessment by a core PCIDT member, to include physical, psychological, social, spiritual needs, and functional status. The PCIDT must also perform on-going assessments of the need for community-based palliative care services;

(B) An assessment of caregiver needs by a core PCIDT member, including providing to the caregiver appropriate referrals to community-based services such as support groups, caregiver respite, and grief or bereavement services;

(C) A documented plan to manage the patient's symptoms and coordinate care in accordance with the patient's needs and goals; and

(D) An ongoing assessment of pain, other physical symptoms, functional status, and psychological symptoms.

(d) Plan of care must be kept in patient’s file.

(5) Provider Qualifications for Palliative Care Program.

(a) Core PCIDT members must be credentialed and recredentialed per CCO requirements in OAR chapter 410, division 141.

(b) Core members of the PCIDT must be:

(A) Certified in palliative care; or

(B) Have documentation of a minimum of sixteen (16) hours of palliative care training.

(i) Training topics must include, but are not limited to:

(I) Advance care planning conversations of POLST and Advance Directive;

(II) Palliative care assessment, including patient assessment; social needs screening; home safety assessment; caregiver assessment; spiritual assessment; functional assessment; and risk assessment;

(III) Basic pain and symptom management;

(IV) Expected disease trajectory for physicians, naturopathic physicians, nurse practitioners, physician assistants and registered nurses.

(ii) Additional training topics may include:

(I) Trauma informed care;

(II) Social determinant of health issues;

(III) Professional boundaries;

(IV) Motivational interviewing.

(6) Palliative Care Team and Services.

(a) The Palliative Care Program maintained by CCO’s must designate an Interdisciplinary team who provide or supervise the care and services offered to the patient. Members of the PCIDT team interact on a regular basis and have a working knowledge of the assessment and care of the patient/family unit by each member of the team. The core members of the PCIDT must:

(A) Develop the plan of care;

(B) Provide or supervise palliative care services;

(D) Follow policies governing the day-to-day provision of palliative care services established by the CCO’s Palliative Care Program.

(b) Palliative care services shall include:

(A) Palliative care assessment;

(B) Advance care conversations including a discussion of POLST and Advance Directive;

(C) Case management and care coordination provided by a registered nurse or other qualified member of the interdisciplinary team;

(D) Symptom assessment and management;

(E) Transitional care management;

(F) Behavioral health and social work services;

(G) 24-hour clinical telephone support;

(H) Spiritual care services;

(I) Education with the patient and their caregivers, including:

(i) Aspects of in-home care, including the safe use of medications, and storage and disposal of medications in the home setting;

(ii) Goals towards the patient being more self-reliant and when to seek higher level of care;

(iii) When to contact Emergency Medical Services (EMS);

(iv) Hospice services availability and eligibility;

(v) Bereavement support and services availability.

(c) The palliative care services, as determined and provided by an interdisciplinary team, must be provided in the patient's choice of residence.

(7) Requirements for Coverage. To be covered, palliative care services must meet the following requirements:

(a) A referral from a patient's primary care or other specialty care provider must be given for palliative care services;

(b) The patient or the patient's representative must elect palliative care services;

(d) Providers must not submit encounter claims for a palliative care and hospice service for the same dates of service.

(8) Patients are no longer eligible for community-based palliative care services under the Palliative Care Program if the patient:

(a) Enrolls in hospice;

(b) Dies;

(d) Experiences improvement of their condition or functional status as documented by a qualified provider's assessment that causes them to no longer meet eligibility criteria within this rule;

(e) Chooses to disenroll from the Palliative Care Program;

(f) Moves out of a palliative care provider's service area;

(g) Engages in behavior that is disruptive, abusive, or is considered a health and safety concern to the patient or a member of the PCIDT, to the extent that delivery of care to the patient, or the ability of the agency to operate effectively, is seriously impaired;

(h) Lives in a home where others engage in behavior that is disruptive, abusive, or is considered a health and safety concern to the patient or a member of the PCIDT, to the extent that delivery of care to the patient, or the ability of the agency to operate effectively, is seriously impaired.

History

Statutory/Other Authority: Oregon Laws 2021 Chapter 462
Statutes/Other Implemented: ORS 413.042
DMAP 142-2024, adopt filed 12/12/2024, effective 01/01/2025

Or. Admin. R. 410-141-3850 Transition of Care

(1) This rule applies to care of a Medicaid member who is enrolled in a CCO (the “receiving CCO”) immediately after disenrollment from a “predecessor plan,” which may be another CCO (including disenrollment resulting from termination of the predecessor CCO’s contract) or Medicaid fee-for-service (FFS). This rule does not apply to a member who is ineligible for Medicaid or who has a gap in coverage following disenrollment from the predecessor plan.

(2) For purposes of this rule, the following additional definitions apply:

(a) “Continued Access to Services” means making available to the member services, prescriptions, and prescription drug coverage consistent with the access they previously had including permitting the member to retain their current provider, even if that provider is not in the CCO network;

(b) “Medically Fragile Children (MFC)” as defined by OAR 411-300-0110 means children that have a health impairment that requires long-term, intensive, specialized services on a daily basis, who have been found eligible for MFC services by the Department of Human Services (DHS);

(c) “Transition of Care Period” means the period of time after the effective date of enrollment with the receiving CCO, during which the receiving CCO must provide continued access to services. The transition of care period lasts for:

(A) Ninety (90) days for members who are dually eligible for Medicaid and Medicare; or

(B) For other members, the shorter of:

(i) Thirty (30) days for physical and oral health and sixty (60) days for behavioral health; or

(ii) Until the enrollee's new PCP (oral or behavioral health provider, as applicable to medical care or behavioral health care services) reviews the member's treatment plan; or the minimum or authorized prescribed course of treatment has been completed.

(3) CCOs shall implement and maintain a transition of care policy that, at a minimum, meets the requirements defined in this rule and 42 CFR § 438.62(b). A receiving CCO must provide continued access to services to, at minimum, the following members:

(a) Medically Fragile Children (MFC);

(b) Breast and Cervical Cancer Treatment program members;

(d) Members receiving services for end stage renal disease, prenatal or postpartum care, transplant services (including pre-transplant and post-transplant services), radiation, or chemotherapy services; and

(e) Any members who, in the absence of continued access to services, may suffer serious detriment to their health or be at risk of hospitalization or institutionalization.

(4) During the Transition of Care Period the receiving CCO shall ensure that any member identified in section (3) of this rule:

(a) Is provided with Continued Access to Services and has support necessary to access those services such as Non-Emergency Medical Transportation (NEMT);

(b) Is permitted to continue receiving services from the member’s previous provider, regardless of whether the provider participates in the receiving CCO’s network;

(c) Is referred to appropriate providers of services that are in the network at the duration of the Transition of Care period;

(d) Notwithstanding section (4)(b) of this rule, the receiving CCO is responsible for continuing the entire course of treatment with the recipient’s previous provider as described in the following service-specific transition of care period situations:

(A) Prenatal and postpartum care;

(B) Transplant services through the first-year post-transplant;

(D) Prescriptions with a defined minimum course of treatment that exceeds the transition of care period.

(e) Where section (4) of this rule allows the member to continue using the member’s previous provider, the receiving CCO shall reimburse non-participating providers consistent with OAR 410-120-1295 at no less than Medicaid fee-for-service rates;

(f) The receiving CCO is not financially responsible for a continuous inpatient hospitalization for which a predecessor CCO was responsible under its contract, in accordance with OARs 410-141-3500, 410-141-3710, and 410-141-3805.

(5) After the Transition of Care Period ends, the receiving CCO remains responsible for care coordination and discharge planning activities as described in OAR 410-141-3860 and OAR 410-141-3870.

(6) The Predecessor Plan shall fully and timely comply with request for historical utilization data and clinical records within seven calendar days of the request from the receiving CCO.

(a) CCOs shall not delay the provision of services if historical utilization data and clinical records is not available in a timely manner;

(b) In such instances, the CCO is required to approve claims for which it has received no historical utilization data and clinical records during the transition of care time period, as if the covered services were prior authorized. CCOs shall have a process for the electronic exchange of, at a minimum, the data classes and elements included in the content standard adopted at 45 CFR 170.213. Such information must be incorporated into the CCO's records about the current member. With the approval and at the direction of a current or former enrollee or the enrollee's personal representative, the CCO must:

(A) Receive all such data for a current member from any other payer that has provided coverage to the enrollee within the preceding 5 years;

(B) At any time the member is currently enrolled in CCO and up to 5 years after disenrollment, send all such data to any other payer that currently covers the enrollee or a payer the enrollee or the enrollee's personal representative specifically requests receive the data; and

(7) The receiving CCO shall follow all service authorization protocols outlined in OAR 410-141-3835 and give the member written notice of any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested or when reducing a previously authorized service authorization. The notice shall meet the requirements of 42 CFR §438.404 and OAR 410-141-3885.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 92-2022, temporary amend filed 12/21/2022, effective 01/01/2023 through 03/31/2023
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3855 Temporary rule language in effect until 10/27/2026. Pharmaceutical Services

(1) Prescription drugs are a covered service for conditions that are described in the funded region of the Prioritized List of Health Services, as described in OAR 410-141-3820. CCOs shall pay for covered prescription drugs except:

(a) As otherwise provided, mental health drugs that are in Standard Therapeutic Class 7 (ataractics-tranquilizers) or Standard Therapeutic Class 11 (psychostimulants-antidepressants) (based on the National Drug Code (NDC) as submitted by the manufacturer to First Data Bank) and are dispensed through a licensed pharmacy;

(b) FDA-approved formulations of valproic acid and its derivatives, lamotrigine, and xanomeline/trospium and those drugs used to treat severe mental health conditions that the Authority specifically carved out from capitation according to section (11) of this rule. This only includes those prescription drugs dispensed through a licensed pharmacy;

(d) Prescriptions for Physician Assisted Suicide under the Oregon Death with Dignity Act, for which payment is governed by OAR 410-121-0150.

(e) Drugs appearing on the High-Cost Drug Carve-Out (HCDCO) List dated 5/1/2026, appearing at www.orpdl.org, and included here by reference. CCOs will be responsible for all other associated costs, including non-emergency medical transportation, care coordination, inpatient hospital services and other medically necessary expenses.

(A) The HCDCO List is limited to drugs determined by the Authority to present extreme financial uncertainty for CCOs. Drugs meeting the following general criteria will be considered by the Authority for inclusion on the HCDCO List:

(i) Have an estimated acquisition cost of $500,000 or more per member over a 12-month period;

(ii) Are indicated for very rare conditions; and

(iii) Have few alternatives, as determined by the Authority.

(B) To add a drug to or remove a drug from the HCDCO List, the CCO shall submit a request to the Authority containing all the following information:

(i) The drug name;

(ii) Whether the drug is recommended to be added to or removed from the HCDCO List;

(iii) The estimated per member acquisition cost of the drug for a 12-month period;

(iv) The FDA-approved indications for the drug;

(v) Any alternative treatments to the drug for these indications; and

(vi) Any additional considerations the Authority should give to adding or removing the drug, such as how the drug presents a financial risk to the CCO which is not adequately contemplated in current capitation rates.

(C) If the Authority approves a CCO request for a drug to be added to or removed from the HCDCO List, the Authority shall revise the HCDCO List and amend subsection (e) of this section (1) according to the rulemaking process described in ORS 183.333-183.335.

(i) For existing drugs whose carve out will have an impact on capitation rates as determined by OHA, the effective date of the change will be:

(I) The following January 1st, for requests submitted before April 1st; or

(II) One year from the following January 1st, for requests submitted on or after April 1st.

(ii) For new drugs or drugs whose carve out will not have an impact on capitation rates as determined by OHA, the effective date of the change will be:

(I) The following May 1st, for requests submitted before April 1st;

(II) The following August 1st, for requests submitted before July 1st;

(III) The following November 1st, for requests submitted before October 1st;

(IV) The following February 1st, for requests submitted before January 1st.

(D) The Authority may add a drug to or remove a drug from the HCDCO List at any time using the rulemaking process described in ORS 183.333-183.335.

(2) CCOs may use the statewide Practitioner-Managed Prescription Drug Plan under ORS 414.330 to 414.337.

(3) CCOs may use a preferred drug list if it allows access to other drug products not on the drug list through prior authorization.

(4) As specified in 45 CFR 156.122 and 42 CFR 438.10, CCOs shall publish up-to-date, accurate, and complete preferred drug lists, including any tiering structures, that have been adopted and any coverage criteria or other restrictions on the way certain drugs may be obtained. CCOs shall ensure that:

(a) The preferred drug list is easily accessible to members and potential members, state and federal government, and the public;

(b) The preferred drug list is accessible on the CCO’s public website in a machine-readable format through a clearly identifiable web link or tab without requiring a member to access account or policy number;

(d) If a CCO has more than one plan, members may be easily able to discern which preferred drug list applies to which plan.

(5) The preferred drug list shall:

(a) Include Federal Drug Administration (FDA) approved drug products for each therapeutic class sufficient to ensure the availability of covered drugs with minimal prior approval intervention by the provider of pharmaceutical services;

(b) Include at least one item in each therapeutic class of over-the-counter medications; and

(6) CCOs shall cover at least one form of contraception within each of the 18 methods identified by the FDA. As set forth in OAR 410-141-3515, the member may refer themselves directly to family planning services without getting a referral from a PCP or other participating providers.

(7) Prior Authorization for prescription drug requests shall be addressed by the CCOs as described in OAR 410-141-3835.

(8) CCOs shall authorize the provision of a drug requested by the Primary Care Provider or referring provider if the prescriber certifies medical necessity for the drug such as:

(a) The equivalent of the drug listed has been ineffective in treatment; or

(b) The drug listed causes or is reasonably expected to cause adverse or harmful reactions to the member.

(9) CCOs must not authorize payment for any Drug Efficacy Study Implementation (DESI) Less Than Effective (LTE) drugs that have reached the FDA Notice of Opportunity for Hearing (NOOH) stage, as specified in OAR 410-121-0420 (DESI)(LTE) Drug List. DESI LTE drugs are identified by the Covered Outpatient Drug (COD) Status equal to 05 or 06 in the federal “Drug Products in the Medicaid Drug Rebate Program” list available at: https://data.medicaid.gov/

(10) The Authority shall pay for a drug that is not included in the global budget pursuant to the Pharmaceutical Services program rules (chapter 410, division 121), unless otherwise provided in this rule. A CCO must not reimburse providers for drugs carved-out in section (1) of this rule.

(11) Making changes to the carve-out list of mental health drugs in subsection (1)(b) of this rule:

(a) Adding mental health drugs to the carve-out list.

(A) A CCO may seek to add drugs by submitting a request to the Authority. The request must contain all the following information:

(i) The drug name;

(ii) The FDA-approved indications that identify the drug may be used to treat a severe mental health condition, along with any other FDA-approved indications; and

(iii) The reason the Authority should consider this drug for carve out.

(B) If the Authority approves a CCO request for a drug not to be paid within the global budget, the Authority shall:

(i) Amend subsection (1)(b) of this rule according to the process described in ORS 183.335(5) within sixty (60) days of the request to exclude the drug from the global budget if the Authority determines that the drug has an approved FDA indication for the treatment of a severe mental health condition such as major depressive, bi-polar, or schizophrenic disorders;

(ii) Within 180 days of amending subsection (1)(b) of this rule as described in subsection (i), adopt this same amendment to subsection (1)(b) using the permanent rulemaking process described in ORS 183.335(1)-(4).

(b) Removing mental health drugs from the carve-out list.

(A) A CCO may seek to remove drugs by submitting a request to the Authority no later than March 1 of any contract year. The request must contain all the following information:

(i) The drug name;

(ii) The FDA approved indications for the drug; and

(iii) The reason the Authority should consider removing this drug from the list of carved out drugs.

(B) If the Authority approves a CCO request for a carved-out drug to be paid within the global budget, the Authority shall include the drug in the global budget for the following January contract cycle.

(C) The Authority may remove drugs in conjunction with a January contract cycle using the rulemaking process described in ORS 183.333-183.335.

(12) CCOs shall submit quarterly encounter data within 45 days after the end of the quarter pursuant to 42 CFR 438.3.

(13) CCOs are encouraged to provide payment only for outpatient and physician-administered drugs produced by manufacturers that have valid rebate agreements in place with the CMS as part of the Medicaid Drug Rebate Program. CCOs may continue to have some flexibility in maintaining preferred drug lists regardless of whether the manufacturers of those drugs participate in the Medicaid Drug Rebate Program.

(14) CCOs shall utilize a Pharmacy and Therapeutics (P&T) committee and a Drug Use Review (DUR) program. The committees may work in tandem or independent of the other, if all committee requirements for both committee types are met:

(a) A P&T committee must maintain written documentation of the rationale for all decisions regarding the drug list development and revisions. The committee shall follow the membership and meeting standards specified in 45 CFR § 156.122(3)(i) and (ii). Meetings shall be held at least quarterly;

(b) CCOs shall provide a detailed description of its P&T committee including its DUR functions on an annual basis. The report shall be in the form and manner required by the OHP. The data requested by the Authority shall be calculated to meet federal reporting obligations;

(c) The committee in its DUR capacity shall assure prescriptions are appropriate, medically appropriate, and not likely to result in adverse medical results. The committee must be designed to educate prescribers and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care. The committee shall include prospective DUR, retrospective DUR, and educational programs as each is defined and described by 42 CFR 456, subpart K and Section 1902(oo) of the Social Security Act [42 U.S.C. 1396a(oo)].

(15) As required by ORS 414.328, CCOs shall implement a synchronization policy for the dispensing of prescription drugs to members of the CCO. A “synchronization policy” means a procedure for aligning the refill dates of a patient’s prescription drugs so that drugs that are refilled at the same frequency may be refilled concurrently.

(16) Enrolled providers are required to check the Prescription Drug Monitoring Program (PDMP) as defined in ORS 431A.655 before prescribing a schedule II controlled substance pursuant to 42 U.S.C 1396w-3a:

(a) Providers shall maintain documentation of the prescription drug history of the individual being treated; and

(b) In the case that an enrolled provider is not able to conduct the PDMP check, the providers shall maintain documentation of efforts, including reasons why the provider was unable to conduct the check;

(A) Individuals receiving hospice care;

(B) Individuals receiving palliative care;

(D) Individuals with sickle cell disease;

(E) Residents of long-term care facilities described in 42 U.S.C. 1396d, or of another facility for which frequently abused drugs are dispensed for residents through a contract with a single pharmacy in accordance with 42 U.S.C. 1396w–3a(h)(2)(B); and

(d) PDMP requirements are in accordance with OAR 333-023-0800 to 333-023-0830.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570–414.686
DMAP 15-2026, temporary amend filed 04/28/2026, effective 05/01/2026 through 10/27/2026
DMAP 13-2026, amend filed 04/27/2026, effective 04/28/2026
DMAP 3-2026, temporary amend filed 01/28/2026, effective 02/01/2026 through 07/30/2026
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 40-2025, amend filed 04/25/2025, effective 05/01/2025
DMAP 136-2024, temporary amend filed 11/08/2024, effective 11/08/2024 through 05/06/2025
DMAP 41-2022, amend filed 03/28/2022, effective 03/28/2022
DMAP 58-2021, temporary amend filed 12/30/2021, effective 01/01/2022 through 03/29/2022
DMAP 41-2021, temporary amend filed 09/20/2021, effective 10/01/2021 through 03/29/2022
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3860 Care Coordination: Administration, Systems and Infrastructure

(1) Coordinated Care Organizations (CCOs) must coordinate services for members in accordance with 42 CFR §438.208, OAR 410-141-3865, OAR 410-141-3870 and this rule. The rules in this division relating to the CCO Care Coordination requirements take precedence over any and all general Care Coordination rules set forth in Oregon Administrative Rules Division 120. This coordination must encompass all services accessed to address their member’s physical, developmental, behavioral, oral and social needs (including Health-Related Social Needs (HRSN) and Social Determinants of Health and Equity (SDOH-E)). To meet these requirements, CCO’s must:

(a) Identify the needs of their members on an initial and ongoing basis as described in OAR 410-141-3865;

(b) Ensure coordinated services are provided to their members as described in OAR 410-141-3870; and

(c) Ensure their members are informed about the availability of Care Coordination and how to access it initially and ongoing.

(2) CCOs must ensure the overall coordination of all services and supports to which their members are entitled, regardless of who provides the service. CCOs are responsible for coordinating with Medicaid Fee-For-Service (FFS), Medicare or Medicare Advantage Plans, Community Mental Health Programs (CMHP), Oregon Department of Human Services (ODHS), including Aging and People with Disabilities (APD), Child Welfare (CW), and Developmental Disability Services (DDS), Oregon Department of Education (ODE), Oregon Youth Authority (OYA), Local Public and Mental Health Authorities and any other institutional, community and social support organizations serving their members, to the extent feasible.

(3) Primary responsibility for Care Coordination is determined based on the Member’s CCO Plan Type.

(a) If a Member is enrolled in Plan Type CCOA or CCOB the CCO is primarily responsible for Care Coordination and must ensure the coordination of all services and supports furnished to the Member by any other entity referenced in (2) of this rule.

(b) If a Member is enrolled in Plan Type CCOE, CCOF or CCOG, the Oregon Health Authority’s Medicaid Fee-For-Service (FFS) program is primarily responsible for Care Coordination. The CCO must proactively collaborate with FFS Care Coordination and other providers serving the Member to maintain awareness of identified needs and any existing Care Plans and to ensure the services covered by the CCO are coordinated.

(4) The entities in Section (2) of this rule may all have some level of responsibility for a Member’s care. Therefore, the fundamental role the CCO must fill is to facilitate, collaborate and oversee any relevant coordinating entities and lead when necessary, as required in Section (3)(a) of this rule.

(5) When a Member is engaged in multiple programs (e.g., Long Term Services and Supports, Intellectual and Developmental Disabilities, Child Welfare, Youth Wraparound, Intensive In-home Behavioral Health Treatment, etc.) where there are care teams or coordinators involved the CCO’s responsibility is to collaborate with those entities who are coordinating services the Member is receiving in order to reduce duplication and identify Care Coordination gaps.

(a) If the CCO is collaborating with another program the CCO is required to be aware of and document the coordinating entities activities to understand and identify additional unmet needs the Member may have that require Care Coordination be provided by the CCO.

(b) The CCO is responsible for leading and facilitating Care Coordination for all needs identified that are not addressed or coordinated by another program or entity.

(6) Care Coordination is intended to continuously:

(a) Improve Member health outcomes;

(b) Support and enable a Member’s ability to manage, maintain and improve any chronic conditions or disabilities;

(d) Reduce health inequities; and

(e) Reduce barriers to accessing health care.

(7) In all aspects of its systems and practice, Care Coordination must be:

(a) Person-centered or person and family-centered for minors under age 18 and for adults age 18 or older, who are under the legal authority of a family member or guardian;

(b) Trauma-informed and responsive;

(d) Accessible to all members, including those with disabilities and persons who experience Limited English Proficiency and equitable access to services, consistent with 42 CFR §435.905, ORS 413.550 and Title VI, §1557 (ACA 1557);

(e) Delivered with a whole-person approach that encourages Member self-determination and autonomy;

(f) Designed to account for the unique contextual needs of various member populations in relation to their families and communities, such as children, youth, young adults, and older adults, so that every Member's needs are identified and addressed in a way that is appropriate for their situation; and

(g) Focused on prevention, safety, early identification, intervention, and ongoing management.

(8) CCOs must develop and continuously improve the infrastructure (e.g., systems, technology solutions, processes, relationships, and agreements) needed to support, enable, and uphold their responsibility to coordinate services for their members. This infrastructure is not limited to, but must address:

(a) Management and implementation, including at minimum:

(A) Implementing and utilizing a care management platform to track and monitor care coordination activities (e.g., document, track, and report care planning activities, goals and outcomes, Members’ care team, communication to/from care team, community resources, completed assessments, identified needs, change in health-related circumstances, communication with individual Members, and timeliness of activities). To the maximum extent feasible, CCOs shall establish system interfaces with community partners and providers.

(B) Implementing and utilizing member data to develop a risk stratification model and mechanism to stratify members by the following risk levels, at a minimum: no- or low-risk, moderate-risk, high-risk. The Oregon Health Authority (Authority) must approve CCOs’ risk stratification mechanisms and algorithms before implementation.

(i) Data sources used to identify risks, risk level and care gaps must include but are not limited to the following sources: claims and utilization data, Health Risk Assessments, functional needs assessments, , referrals, event notifications, and other available resources to inform physical, developmental, behavioral, oral and social needs (including Health-Related Social Needs (HRSN) and Social Determinants of Health and Equity (SDOH-E)); and

(ii) Risk scores shall be utilized, in conjunction with the application of appropriate clinical subjectivity by health care providers to further interpret objective and subjective patient information to determine the Member’s risk level and inform the overall care planning process. That shall be documented in the Care Profile and align the CCOs efforts and activities to the level of intensity and intervention the Member requires ; and

(iii) Continuous and ongoing data mining and identification of additional care gaps shall inform updates to the Member’s risk level and interventions needed.

(C) Regularly monitoring population level trends to determine and identify cohorts of the population requiring Care Coordination due to a Rising Risk or emergent need;

(D) Developing monitoring mechanisms to regularly track timeliness, adequacy, and effectiveness of Care Coordination efforts and outreach by the CCO and providers, or subcontracted entity if Care Coordination is delegated;

(E) Tracking data required for reporting and ongoing improvement efforts;

(F) Maintaining policies, procedures, workflows, and desk processes to support CCO staff or subcontractors in managing Care Coordination activities;

(G) CCOs shall follow the grievance and appeal system requirements outlined in OAR 410-141-3875, OAR 410-141-3880, OAR 410-141-3885, OAR 410-141-3890, OAR 410-141-3895, OAR 410-141-3900, OAR 410-141-3905, OAR 410-141-3910, and OAR 410-141-3915 for grievances and appeals pertaining to Care Coordination.

(H) Abide by, or enter into as needed, any agreements or Memoranda of Understanding (MOUs) governing coordination with other entities described in (2) of this rule, including at minimum but not limited to, Aging and People with Disabilities (APD) or Type B Area Agency on Aging (AAA) for Long Term Services and Supports.

(I) Maintaining training and qualification requirements for CCO staff and subcontracted entities;

(J) Using creative and innovative strategies to develop and build member engagement;

(K) Maintaining and publishing a contact point for use at any time by members, their representative or guardian, providers or other entities.

(b) Record keeping, mutual exchange of information, and privacy, including at minimum:

(A) Documentation and record keeping of member information in accordance with OAR 410-141-3520;

(B) The systems and processes (e.g., data sharing agreements, electronic health information exchange) needed for mutual exchange of information between the CCO, providers and community partners;

(C) Developing and entering into agreements or Memoranda of Understanding (MOUs) with providers and/or member serving systems or organizations not contracted with the CCO to ensure mutual exchange of information of a Member’s physical, developmental, behavioral, oral, and social needs (including Health-Related Social Needs (HRSN) and Social Determinants of Health and Equity (SDOH-E)) information across all entities, providers, and systems involved in Care Coordination, to the extent feasible;

(D) Requiring Primary Care and other CCO contracted providers to communicate and coordinate care with each other and with the CCO in a timely manner, using electronic health information technology, as available, or through other mechanisms (e.g. paper-based systems); and

(E) The Member having access to, and the ability to share, protected health information with others involved in their care as set forth in 45 CFR § 164.524. Privacy protections outlined in Health Insurance Portability and Accountability Act and Privacy and Security Rules, privacy administrative rules in Chapter 407, Division 014, ORS 192.553 to 192.581, and ORS 646A.600 to 646A.628.

(A) Establishing, maintaining and monitoring a network of participating providers to ensure the provision of an ongoing source of care appropriate to the needs of its members in accordance with OAR 410-141-3515;

(B) Contracting with Patient-Centered Primary Care Homes (PCPCH) to provide members a consistent and stable relationship with a care team, and supporting and collaborating with them in the overall coordination of the Member’s care;

(C) Developing and entering into agreements, memoranda of understandings (MOUs) with providers and other entities not contracted with the CCO, to ensure a Member’s access to coordinated physical, developmental, behavioral, oral, and social needs (including Health-Related Social Needs (HRSN) and Social Determinants of Health and Equity (SDOH-E)) services across multiple providers;

(D) Using Value Based Payments to encourage specialty and Primary Care Providers to coordinate care;

(E) Assignment to a Primary Care Provider if the Member has not selected a Primary Care Provider by the 90th day after enrollment in the CCO. The CCO shall provide notice of the assignment to the Member and to the Primary Care Provider.

(i) A Member may select a different Primary Care Provider at any time and/or request assistance with selecting an appropriate provider.

(ii) Eligible Members who are American Indian/Alaska Native may select as their Primary Care Provider:

(I) An Indian health care provider (IHCP) who is a Primary Care Provider within the CCO’s provider network; or

(II) An out-of-network IHCP from whom the Member is otherwise eligible to receive such primary care services.

(F) Maintenance of a policy and procedure that informs members, their Non-Emergency Medical Transportation (NEMT) providers and call centers of the availability of NEMT services for Care Coordination activities.

(d) Subcontractor and provider oversight, including at minimum:

(A) Ongoing and regular monitoring and reporting to ensure compliance, and appropriate support, for any delegated Care Coordination activities, in accordance with 42 CFR §438.208, OAR 410-141-3505, OAR 410-141-3865, OAR 410-141-3870, and this rule;

(B) CCOs must take corrective action to address any deficiencies identified through monitoring and reporting.

(9) CCOs shall monitor and document their Care Coordination activities and the effectiveness of those efforts in a Care Coordination report submitted to the Authority under the timelines specified by the Authority in CCO Contract.

(a) The Authority shall provide tools and additional guidance specific to reporting requirements on the CCO Contract Forms webpage https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(b) The Authority may determine additional deliverables are necessary to appropriately oversee CCOs’ implementation of Care Coordination requirements.

(10) If CCOs are not in compliance with these rules OHA may impose sanctions as described in CCO contract and OAR 410-141-3530.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 140-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 82-2024, minor correction filed 04/01/2024, effective 04/01/2024
DMAP 37-2024, amend filed 01/25/2024, effective 02/01/2024
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 6-2021, temporary amend filed 02/10/2021, effective 02/10/2021 through 08/08/2021
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3865 Care Coordination: Identification of Member Needs

(1) In order to coordinate a Member’s services as described in this rule, OAR 410-141-3860 and OAR 410-141-3870, Coordinated Care Organizations (CCOs) must have mechanisms in place to identify the Member’s physical, developmental, behavioral, oral and social needs (including Health Related Social Needs (HRSN) and Social Determinants of Health and Equity (SDOH-E)), goals, and preferences of Members on an initial and ongoing basis.

(2) CCOs must conduct an initial Health Risk Assessment (HRA), as defined in OAR 410-141-3500, with subsequent documented attempts as described in sub-paragraph (f) (A) of section (2) of this rule, within ninety (90) days of enrollment, or sooner if a Member’s health status requires, and must:

(a) Conduct the HRA according to the evaluation checklist provided by the Oregon Health Authority (OHA) and available on the CCO Contract Forms page;

(b) Make the HRA available to members, their representative or guardian orally, in writing, or online;

(d) Review and document a Member’s HRA in their Care Profile or the member’s general health care record, if applicable, in accordance with OAR 410-141-3870(4)(h);

(e) Share with other entities and providers serving the member the results of any HRA to reduce duplication of those activities; and

(f) When the Member, their representative or guardian has not returned or responded to the HRA, the CCO must:

(A) Follow up with the Member if additional information, or support with completion, is needed. This shall include;

(i) Making a minimum of two (2) additional attempts to contact the Member to facilitate completion and identification of the Member’s needs; and

(ii) The attempts to reach a Member shall utilize two (2) mixed modalities (e.g., paper, digital or verbal), , on different days and at different times; and

(iii) Shall be in the Member’s preferred method of communication and language. Auxiliary Aids and Services and Alternate Formats must be made available upon request.

(B) Use other available data sources, including but not limited to those identified in OAR 410-141-3860(8) and (3) of this rule, to identify sufficient information to assign a risk level to the Member; and

(3) CCOs shall consider relevant information from a variety of sources to inform the development or update of a Member’s Care Profile, and/or Care Plan, if applicable, as described in OAR 410-141-3870(4) and (5). This includes, but is not limited to:

(a) Progress notes from any entity involved in the Members care coordination team;

(b) Any relevant assessments;

(d) Social needs (including Health Related Social Needs (HRSN) and Social Determinants of Health and Equity (SDOH-E))

(e) Utilization of services as a result of claims review;

(f) Information received from the Member, their representative or guardian or other involved providers or community supports.

(g) Change in health-related circumstances which is defined as, but not limited to, any of the following occurrences:

(A) Hospital ER visits, hospital admissions or discharges (including Institutions for Mental Disease);

(B) Crisis Services (i.e., Mobile Crisis response, Mobile Response and Stabilization Services);

(D) Newly diagnosed or significant change to a Chronic disease or condition ;

(E) Newly diagnosed or significant change to a Behavioral health diagnosis or condition;

(F) Newly diagnosed or significant change to an Intellectual/Developmental Disability (I/DD) diagnosis;

(G) Event that poses a significant risk to the Member that is likely to occur, reoccur or escalate without intervention;

(H) Recent homelessness, or at risk for homelessness or non-placement;

(I) Two or more billable primary ICD-10 Z code diagnoses within one (1) month resulting in a change in health status and/or risk level;

(J) Two or more caregiver placements within past six (6) months;

(K) Discharge from carceral settings (i.e., state or federal prisons, local correctional facilities, juvenile detention facilities or Tribal correctional facilities), back to the community or another residential or care setting;

(L) Admit to or discharge from a residential or long-term care setting back to the community or another care setting;

(M) Exit from Condition Specific Program or Facility as defined in OAR 410-141-3500;

(N) Enrollment or disenrollment in other service programs such as Long-Term Services and Supports (LTSS), Intellectual/Developmental Disability (I/DD) services or Children’s Intensive In-home services;

(O) Orders for Home Health or Hospice services;

(P) Newly identified or change to an identified Health Related Social Need (HRSN);

(Q) An identified gap in network adequacy that leaves the Member without a needed service or care;

(R) Life span developmental transitions such as a transition from pediatric to adult health care;

(S) Entry into, discharge from , instability, or placement disruption while in foster care.

(4) CCOs must implement mechanisms, including but not limited to the HRA and any additional relevant assessments described above, to identify the risk level and needs for:

(a) Members with Special Health Care Needs (SHCN) as defined in OAR 410-120-0000and

(b) Members requiring Medicaid Funded Long Term Services and Supports (LTSS) as defined in OAR 410-141-3500.

(5) If at any time the Member is identified as potentially eligible for, or requiring LTSS, or having a Special Health Care Need, the CCO must also ensure those members are comprehensively assessed, per 42 CFR 438.208(c)(2), as soon as their health condition requires, to identify those members who have an ongoing special condition that requires either a course of treatment or regular care monitoring.

(6) CCOs must ensure appropriate and prompt referral of Members identified in (5) of this rule to the Oregon Department of Human Services (ODHS), including Aging and People with Disability (APD) programs, the Office of Developmental Disabilities Services (ODDS), Local Mental Health Authorities (LMHA) or other service programs where appropriate for completion of a comprehensive assessment and potential service planning.

History

Statutory/Other Authority: 414.615, 414.625, 414.635, 414.651 & ORS 413.042
Statutes/Other Implemented: ORS 414.610–414.685
DMAP 140-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 37-2024, amend filed 01/25/2024, effective 02/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3870 Care Coordination: Service Coordination

(1) Coordinated Care Organizations (CCOs) must ensure all services accessed by members are coordinated according to the needs of members, following the requirements in OAR 410-141-3860, OAR 410-141-3865 and in this rule.

(2) Upon enrollment, CCOs must act promptly to ensure services are coordinated for members needing Urgent Care Services or Emergency Services as defined in OAR 410-120-0000, even if the Member has not yet selected a Primary Care Provider (PCP) or completed a Health Risk Assessment (HRA).

(3) CCOs must formally designate a position or team as primarily responsible to coordinate individual services accessed by the Member and must provide information to the Member on how to contact their designated person or team initially and when the designated position or team changes.

(4) CCOs shall utilize a Care Profile for all members as defined in OAR 410-141-3500. The Member Care Profile must identify:

(a) The Member’s identifying demographic information;

(b) The Member’s communication preferences and needs (e.g. preferred language, method of communication, Alternate Formats, Auxiliary Aids and Services);

(c) The Member's care team, along with their contact information, role, and any assigned Care Coordination responsibilities. This must include, but is not limited to;

(A) The persons or teams formally designated by the CCO as primarily responsible for coordinating the services accessed by the Member;

(B) All providers serving the Member, including, at minimum, their Primary Care Provider; and

(d) A summary of the Member’s needs; and

(e) The Member’s preferences, when available, to the extent the Member desires to participate; and

(f) The Member’s health risk score and risk level, as described in OAR 410-141-3860;

(g) Any open or closed Care Plans; and

(h) An overview of the supports, services, activities, and resources that have been or shall be deployed to meet the Member’s identified needs.

(5) CCOs must ensure services are actively coordinated for members when requested by the Member, their representative or guardian, an involved provider or entity, or when required by the Member’s needs and risk level as identified in the Member’s Care Profile. This coordination is accomplished through the development and implementation of a Care Plan that scales in complexity relative to the needs, goals, preferences, and circumstances of the Member.

(a) CCOs shall consider the Member’s identified risk level to determine if a Care Plan is required.

(A) Members in the no- or low-risk levels do not require a Care Plan unless the Member’s needs change resulting in a higher risk level or when the Member requests it;

(B) Members within the moderate-risk and high-risk levels, or who require Long Term Service and Supports (LTSS) must have a Care Plan developed.

(C) For Members identified as moderate or high risk who decline participation in Care Plan development, CCOs shall ensure Care Plans at minimum document:

(i) The Member’s physical, developmental, behavioral, oral and social needs (including Health Related Social Needs and Social Determinants of Health and Equity), when available; and

(ii) The services and activities the CCO have or will deploy to focus on mitigation of the Member’s identified risks and level; and

(iii) The outreach attempts and opportunities for engagement the CCO continues to provide to the Member; and

(iv) The reason the Member has declined or is otherwise unable to participate in the development of their Care Plan.

(D) For Members receiving Long Term Services and Supports (LTSS), the CCO shall have access to or integrate any service or Care Plans developed by entities listed in OAR 410-141-3865(6) into the Member’s Care Profile or Care Plan.

(b) The Care Plan is developed or revised as required in (5)(d) of this rule and in alignment with:

(A) The Member’s identified needs and risk level; and

(B) With identification of the Member’s goals and preferences, when available, to the extent the Member desires or is able to participate; and

(C) By incorporating information from any relevant assessments, treatment and service plans from providers or community partners involved in the Member’s care, to the maximum extent feasible;

(D) In consultation with any other provider, case manager, or entity providing services to, or coordinating care for, the Member;

(E) In consultation with a clinician that has the appropriate clinical qualifications and expertise to review and revise the Care Plan considering the Member’s complex physical, developmental, behavioral or oral health care needs including clinical subjectivity;

(F) In accordance with a Member’s updated risk level as described in (4)(f) of this rule;

(G) With the Member, their representative or guardian’s participation to the extent they desire or are able to participate. The Member, their representative or guardian shall be satisfied with and understand the Care Plan, including any of their own roles and responsibilities.

(i) If participation in creating a Member’s Care Plan may be significantly detrimental to the Member’s care or health, the Member, the Member’s caregiver, or the Member’s family may be excluded from the development of a Care Plan;

(ii) The CCO must document the reasons for the exclusion, including a specific description of the risk or potential harm to the Member, and describe what attempts were made to address the concern(s); and

(iii) This decision must be reviewed prior to each significant Care Plan update resulting from a health-related circumstance change as set forth in OAR 410-141-3865(3)(g). The decision to continue the exclusion shall be documented.

(H) In accordance with state quality assurance and utilization review standards, as applicable.

(c) After development of the Care Plan, CCOs must make it promptly available to the Member, the Member’s representative or guardian and to all relevant providers rendering services to the Member who shall coordinate and provide services according to it:

(A) The Member, the Member’s representative or guardian must be provided immediate electronic access, or a copy in the Member’s preferred method of communication and in the Member’s preferred language. Auxiliary Aids and Services and Alternate Formats must be made available upon request of the member at no cost within five (5) business days of the request.

(B) If the CCO requires Care Plans to be approved, approval must be timely, according to a Member’s needs; and

(C) If providing the Member with a copy of or access to their full Care Plan may be significantly detrimental to their care or health, as determined by the Member’s care team, CCOs may withhold from the Member, only those parts of the plan that are determined to be detrimental. The CCO must:

(i) document the reasons for withholding the full or partial Care Plan, including a specific description of the risk or potential harm to the Member, and describe what attempts were made to address the concern(s); and

(ii) This decision to withhold the Care Plan in full or in part must be reviewed prior to each Care Plan update, and the decision to continue withholding the Care Plan in full or in part shall be documented.

(d) Open Care Plans must be reviewed and revised at least annually, or

(A) When a Member, Member representative or guardian, or any provider serving the Member requests a review or revision; or

(B) Upon a change in health-related circumstances as described in OAR 410-141-3865(3)(g).

(e) The Care Plan may be closed and the Member shall continue with Care Profile tracking when;

(A) No longer warranted by the Member’s risk level or circumstances; or

(B) Requested by the Member, their representative or guardian when the member no longer desires to participate; or

(C) There is no contact with the Member, their representative or guardian after a minimum of three (3) attempts of outreach, utilizing at least two (2) mixed modalities (e.g., paper, digital or verbal) including the Member’s preferred method of communication and language, over a sixty (60) day period and with consultation and agreement of all available care team Members.

(D) If the associated risk level of a Member remains a moderate, high or LTSS and the Member no longer wishes to participate the CCO must close the Care Plan and transition to a CCO directed Care Plan as outlined in (5)(a)(B) and (5)(a)(C) of this rule.

(6) CCOs shall ensure Care Coordination for all members, regardless of where the Member is receiving services.

(a) If members experience a Care Setting Transition CCOs must ensure:

(A) Members are transitioned into the most appropriate independent and integrated community settings and provided follow-up services as medically necessary and appropriate prior to discharge to facilitate successful handoff to community providers;

(B) Appropriate discharge planning and Care Coordination for adults who were Members upon entering the Oregon State Hospital (OSH) and who shall return to their home CCO upon discharge from the Oregon State Hospital;

(C) Care Coordination and discharge planning for out of service area placements, for which an exception shall be made to allow the Member to retain Home CCO enrollment while the Member’s placement is a Temporary Residential Placement as defined in OAR 410-141-3500, or elsewhere in accordance with OAR 410-141-3815. CCOs shall, prior to discharge, coordinate care in accordance with a Member’s discharge plan.

(b) Coordinate and authorize care when it has been deemed medically appropriate and medically necessary to receive services outside of the service area because a provider specialty is not otherwise contracted with the CCO;

(d) If members are transitioning between CCOs or to or from fee-for-service (FFS) as set forth in OAR 410-141-3850;

(e) Post Hospital Extended Care must be provided in accordance with OAR 411-070-0033:

(A) Post Hospital Extended Care (PHEC) is a benefit of up to one hundred (100) days included within the Global Budget and the CCO shall pay for the full one hundred (100) day PHEC benefit when the full one hundred (100) days is required by the discharging provider. CCOs shall make the benefit available to non-Medicare Members who meet Medicare criteria for a post-Hospital Skilled Nursing Facility placement.

(B) CCOs shall notify the Member’s local ODHS APD office prior to the Member being admitted to PHEC. Upon receipt of such notice, CCO and the Member’s APD office must promptly begin appropriate discharge planning.

(C) CCOs shall notify the Member and the PHEC facility of the proposed discharge date from such PHEC facility no less than two (2) full days prior to discharge.

(D) CCOs shall ensure that all of a Member’s post-discharge services and care needs are in place prior to discharge from the PHEC, including but not limited to Durable Medical Equipment (DME), medications, home and Community based services, discharge education or home care instructions, scheduling follow-up care appointments, and provide follow-up care instructions that include reminders to:

(i) attend already-scheduled appointments with Providers for any necessary follow-up care appointments the Member may need; or

(ii) schedule follow-up care appointments with Providers that the Member may need to see;

(iii) or both (i) and (ii).

(E) CCOs shall provide the PHEC benefit according to the criteria established by Medicare, as cited in the Medicare Coverage of Skilled Nursing Facility Care available by calling 1-800-MEDICARE or at www.medicare.gov/publications

(F) CCOs are not responsible for the PHEC benefit unless the Member was enrolled with the CCO at the time of the hospitalization preceding the PHEC facility placement.

(7) In addition to the care planning requirements above, for LTSS or Special Health Care Needs Members as defined in OAR 410-120-0000 that are assessed according to OAR 410-141-3865(5) to have an ongoing special condition that requires a course of treatment or regular care monitoring or identified as high risk:

(a) CCOs must consider the above members, according to their needs, during Interdisciplinary Team Meetings which are convened and facilitated as needed according to the Member’s Care Plan, including a post-transition meeting of the interdisciplinary team within fourteen (14) days of a transition between levels, settings or episodes of care. These meetings must:

(A) Include the Member, their representative or guardian, unless the Member declines or the Member’s participation is determined to be significantly detrimental to the Member’s health, in accordance with (5)(b)(G) of this rule;

(B) Invite and consider relevant information from all providers and other entities serving the Member including but not limited to those listed in OAR 410-141-3860(2); and

(i) Describe the clinical interventions recommended to the treatment team and identify the frequency of necessary Interdisciplinary Team Meetings appropriate to meet the Care Plan needs;

(ii) Create a space for the Member to provide feedback on their care, self-reported progress towards their Care Plan goals, and their strengths exhibited in between current and prior meeting;

(iii) Identify coordination gaps and strategies to improve Care Coordination with the Member’s service providers;

(iv) Develop strategies to identify, address, monitor and follow up on needed referrals for specialty care, routine health care services (including medication monitoring), other community programs or social need services; and

(v) Align and update the Member’s individual Care Plan and share the plan in accordance with (5)(c) of this rule.

(b) CCOs must implement a mechanism to provide direct access to specialists, e.g., a standing referral or an approved number of visits, as appropriate for the Member’s condition and identified needs.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 140-2024, amend filed 12/06/2024, effective 01/01/2025
DMAP 83-2024, minor correction filed 04/01/2024, effective 04/01/2024
DMAP 37-2024, amend filed 01/25/2024, effective 02/01/2024
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3875 MCE Grievances & Appeals: Definitions and General Requirements

(1) The following definitions apply for purposes of this rule and OAR 410-141-3835 through OAR 410-141-3915:

(a) “Appeal” means a review by an Managed Care Entities (MCE), pursuant to OAR 410-141-3890 of an adverse benefit determination;

(b) “Adverse Benefit Determination” means any of the following, consistent with 42 CFR § 438.400(b):

(A) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

(B) The reduction, suspension, or termination of a previously authorized service;

(C) A denial, in whole or in part, of a payment for a service. A payment denied solely because the claim does not meet the definition of a “clean claim” at CFR 447.45(b) is not an adverse benefit determination;

(D) The failure to provide services in a timely manner pursuant to OAR 410-141-3515;

(E) The MCE’s failure to act within the timeframes provided in these rules regarding the standard resolution of grievances and appeals;

(F) For a resident of a rural area with only one MCE, the denial of a member’s request to exercise their legal right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network; or

(G) The denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities

(c) “Clean claim” means one that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in a State’s claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. For the purpose of this rule, pharmacy claims processed at point-of-sale (POS) that are rejected or denied shall not be considered “clean claims” that may trigger an Notice of Adverse Benefit Determination (NOABD);

(d) “Contested Case Hearing” means a hearing before the Authority under the procedures of OAR 410-141-3900 and OAR 410-120-1860;

(e) “Continuing benefits” means a continuation of benefits in the same manner and same amount while an appeal or contested case hearing is pending, pursuant to OAR 410-141-3910;

(f) “Grievance” means a member's expression of dissatisfaction to the MCE or to the Authority about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member’s rights regardless of whether remedial action is requested. A Grievance also includes a member’s right to dispute an extension of time proposed by the MCE to make an authorization decision;

(g) “Member” for actions taken regarding grievances and appeals, “member” includes, as appropriate, the member, the member’s representative, and the representative of a deceased member’s estate. With respect to MCE notification requirements, a separate notice must be sent to each individual who falls within this definition;

(h) “Notice of Adverse Benefit Determination” means the notice must meet all requirements found at 42 CFR 438.400.

(2) MCEs shall establish and have an Authority approved process and written procedures for compliance with grievance and appeals requirements that shall include the following:

(a) Member rights to file a grievance at any time for any matter other than an adverse benefit determination;

(b) Member rights to appeal and request an MCE review of a notice of adverse benefit determination, including the ability of providers and authorized representatives to appeal on behalf of a member;

(c) Member rights to request a contested case hearing regarding an MCE notice of adverse benefit determination once the plan has issued a written notice of appeal resolution under the Administrative Procedures Act;

(d) An explanation of how MCEs shall accept, acknowledge receipt, process, and respond to grievances, appeals, and contested case hearing requests within the required timeframes;

(e) Compliance with grievance and appeals requirements as part of state quality strategy and to enforce a consistent response to complaints of violations of consumer rights and protections;

(A) Provide the member a reasonable opportunity to present evidence and testimony and make legal and factual arguments in person as well as in writing;

(B) The MCE shall inform the member of the limited time available for this sufficiently in advance of the resolution timeframe for both standard and expedited appeals;

(C) The MCE shall provide the member the member’s case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCE (or at the direction of the MCE) in connection with the appeal of the adverse benefit determination at no charge and sufficiently in advance of the standard resolution timeframe for appeals; and

(D) Ensure documentation of appeals in an appeals log maintained by the MCE that complies with OAR 410-141-3915 and is consistent with contractual requirements.

(3) The MCE shall provide information to members regarding the following:

(a) An explanation of how MCEs shall accept, process, and respond to grievances, appeals, and contested case hearing requests, including requests for expedited review of grievances and appeals;

(b) Member rights and responsibilities; and

(c) How to file for a hearing through the state’s eligibility hearings unit related to the member’s current eligibility with OHP.

(4) The MCE shall adopt and maintain compliance with grievances and appeals process timelines in 42 CFR §§ 438.408 (a) and these rules.

(5) Upon receipt of a grievance or appeal, the MCE shall:

(a) Within (5) five business days, resolve or acknowledge receipt of the grievance or appeal to the member and the member’s provider where indicated;

(b) Give the grievance or appeal to staff with the authority to act upon the matter;

(c) Consistent with confidentiality requirements, obtain documentation of all relevant facts concerning the issues, including taking into account all comments, documents, records, and other information submitted by the member without regard to whether the information was submitted or considered in the initial adverse benefit determination or resolution of grievance;

(d) Ensure staff and any consulting experts making decisions on grievances and appeals are:

(A) Not involved in any previous level of review or decision making nor a subordinate of any such individual;

(B) Health care professionals with appropriate clinical expertise in treating the member’s condition or disease, if the grievance or appeal involves clinical issues or if the member requests an expedited review. Health care professionals shall make decisions for the following:

(i) An appeal of a denial that is based on lack of medically appropriate services or involves clinical issues;

(ii) A grievance regarding denial of expedited resolution of an appeal or involves clinical issues.

(C) Taking into account all comments, documents, records, and other information submitted by the member without regard to whether the information was submitted or considered in the initial adverse benefit determination;

(D) Not receiving incentivized compensation for utilization management activities by ensuring that individuals or entities who conduct utilization management activities are not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member.

(6) The MCE shall analyze all grievances, appeals, and hearings in the context of quality improvement activity pursuant to OAR 410-141-3525 and 410-141-3875.

(7) MCEs shall keep all health care information concerning a member's request confidential, consistent with appropriate use or disclosure as defined in 45 CFR 164.501 and include providing member assurance of confidentiality in all written, oral, and posted material in grievance and appeal processes.

(8) The following pertains to the release of a member’s information:

(a) The MCE and any provider whose authorizations, treatments, services, items, quality of care, or requests for payment are involved in the grievance, appeal, or hearing may use this information without the member’s signed release for purposes of:

(A) Resolving the matter; or

(B) Maintaining the grievance or appeals log as specified in 42 CFR 438.416.

(b) If the MCE needs to communicate with other individuals or entities not listed in subsection (a) to respond to the matter, the MCE shall obtain the member’s signed release and retain the release in the member’s record.

(9) The MCE shall provide Members with any reasonable assistance in completing forms and taking other procedural steps related to filing grievances, appeals, or hearing requests. Reasonable assistance includes but is not limited to:

(a) Assistance from certified community health workers, peer wellness specialists, or personal health navigators to participate in processes affecting the member’s care and services;

(b) Free interpreter services or other services to meet language access requirements where required in 42 CFR §438.10;

(c) Providing auxiliary aids and services upon request including but not limited to toll-free phone numbers that have adequate TTY/TTD and interpreter capabilities; and

(d) Reasonable accommodation or policy and procedure modifications as required by any disability of the member.

(10) The MCE, its subcontractors, and its participating providers may not:

(a) Discourage a member from using any aspect of the grievance, appeal, or hearing process or take punitive action against a provider who requests an expedited resolution or supports a member’s appeal;

(b) Encourage the withdrawal of a grievance, appeal, or hearing request already filed; or

(c) Use the filing or resolution of a grievance, appeal, or hearing request as a reason to retaliate against a member or to request member disenrollment.

(11) In all MCE administrative offices and in those physical, behavioral, and dental health offices where the MCE has delegated responsibilities for appeal, hearing request, or grievance involvement, the MCE shall have the following forms available:

(a) OHP Complaint Form (OHP 3001);

(b) MCE appeal forms (OHP 3302; or approved facsimile);

(12) In all investigations or requests from the Department of Human Services Governor’s Advocacy Office, the Authority’s Ombudsperson or hearing representatives, the MCE, and participating providers shall cooperate in ensuring access to all activities related to member appeals, hearing requests, and grievances including providing all requested written materials in required timeframes.

(13) The member may request continuation of benefits from their MCE for services that were discontinued. If the member qualifies for continuation of benefits the MCE must provide the services while the appeal or administrative hearing is pending pursuant to OAR 410-141-3910.

(14) Adjudication of appeals in a member grievance and appeals process may not be delegated to a subcontractor. If the MCE delegates any other portion of the grievance and appeal process to a subcontractor, the MCE must, in addition to the general obligations established under OAR 410-141-3505, do the following:

(a) Ensure the subcontractor meets the requirements consistent with this rule and OAR 410-141-3715 through 410-141-3915;

(b) Monitor the subcontractor’s performance on an ongoing basis;

(c) Perform a formal compliance review at least once a year to assess performance, deficiencies, or areas for improvement; and

(d) Ensure the subcontractor takes corrective action for any identified areas of deficiencies that need improvement.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3880 Grievances & Appeals: Grievance Process Requirements

(1) A member and, with the written consent of the member, a provider or an authorized representative may file a grievance at any time either orally or in writing, on behalf of a member. The grievance may be filed with the MCE or the Authority. If the grievance is filed with the Authority, it shall be promptly forwarded to the MCE.

(2) For standard resolution of a grievance, the MCE shall resolve each grievance and provide notice of the disposition as expeditiously as the member’s health condition requires. The MCE shall:

(a) Within five business days from the date of the MCEs receipt of the grievance, notify the member in their preferred language that a decision on the grievance has been made and what that decisions is; or

(b) Promptly, but in no event more than five business days after the date of the MCE’s receipt of the grievance, notify the member in their preferred language that there shall be a delay in the MCE’s decision of up to 30 days from the date on which the grievance was received by the MCE. The written notice shall specify why the additional time is necessary.

(3) The MCE shall ensure that the individuals who make decisions on grievances follow all requirements in OAR 410-141-3875 MCE Grievance and Appeals System General Requirements.

(4) When informing members of the MCE’s decision, the MCE:

(a) May provide its decision related to oral grievances orally but shall also, in call instances respond to oral grievances in writing. Both oral and written responses shall be made in the member’s preferred language;

(b) Shall address each aspect of the grievance and explain the reason for the decision;

(c) Shall respond in writing to written grievances in the member’s preferred language. In addition to written responses, the MCE may also respond orally in the member’s preferred language; and

(d) Shall notify members who are dissatisfied with the disposition of a grievance that they may present their grievance to the Department of Human Services (Department) Client Services Unit or the Authority’s Ombudsperson.

(5) In compliance with Title VI of the Civil Rights Act and ORS Chapter 659A, the MCE shall review and report to the Authority, as outlined in the CCO contract, member complaints related to their race and ethnicity, gender identity, sexual orientation, socioeconomic status, country of origin, and disability status.

(6) If an MCE receives a grievance related to a member’s entitlement of continuing benefits in the same manner and same amount during the transition of transferring from one MCE to another MCE as defined in OAR 410-141-3850, the MCE shall log the grievance and work with the receiving or sending MCE to ensure continuity of care during the transition.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3885 Grievances & Appeals: Notice of Action/Adverse Benefit Determination

(1) When a Managed Care Entity (MCE) has made an adverse benefit determination, the MCE shall give the requesting provider, the Member and the member’s representative a written Notice of Adverse Benefit Determination (NOABD). The notice shall:

(a) Comply with the Authority’s formatting and readability standards in OAR 410-141-3585 and 42 CFR § 438.10 and be written in plain language sufficiently clear that a layperson could understand the notice and make an informed decision about appealing and following the process for requesting an appeal;

(b) For timing of notices, follow timelines required for the specific service authorization or type via oral and written mechanisms for any service request of the member or the member’s provider outlined in OAR 410-141-3835 MCE Service Authorization or otherwise specified in this rule.

(2) The following are notice requirements for preservice denials:

(a) Meet the content notice requirements specified in 42 CFR § 438.404 and in the MCE contract, including the following information:

(A) MCE contact information and subcontractor contact information including name, address, and telephone number, if applicable, included in the ABD notice excluding any cover pages;

(B) Date of the notice;

(C) For notices not pertaining to non-emergency medical transportation (NEMT) services, the name of the member’s Primary Care Practitioner (PCP), Primary Care Dentist (PCD), or Behavioral Health (BH) professional if the member has an assigned practitioner or the most specific information available if a member is not assigned to a practitioner due to the clinic/facility model. If the member has not been assigned a practitioner because they enrolled in the MCE within the last ninety (90) days, the NOABD shall state PCP, PCD, BH provider assignment has not occurred;

(D) Member’s name, date of birth, address, and OHP member ID number;

(E) Service requested and the adverse benefit determination the MCE intends to make, including whether the MCE is denying, (in whole or part) terminating, suspending, or reducing a service;

(F) Date service was requested by the provider or member;

(G) Name of the provider who requested the service;

(H) Effective date of the adverse benefit determination if different from the date of the notice;

(I) Diagnosis and procedure codes submitted with the authorization request including a description of all codes in plain language. For services that do not include a procedure code a description of the requested service;

(J) Whether the MCE considered other conditions such as co-morbidity factors if the condition was below the funding line on the Prioritized List of Health Services pursuant to OAR 410-141-3820 and 410-141-3830;

(K) Clear and thorough explanation of the specific reasons for the adverse benefit determination. If the service has been denied as the provider did not submit the supporting documentation include a statement in the NOABD that before denying the requested service attempts by the MCE have been made to obtain the documentation from the provider;

(L) A reference to the specific statutes and administrative rules to the highest level of specificity for each reason and specific circumstance identified in the NOABD;

(M) The Member, member representative or, the provider with the member’s written consent as required under OAR 410-141-3890(1), may file a written or oral appeal of the MCE’s adverse benefit determination with the MCE within sixty (60) days from the date of the NOABD, including information on exhausting the MCE’s one level of appeal, and the procedures to exercise that right;

(N) The Member, member representative or the provider with the member’s written consent has the right to request a contested case hearing either orally or in writing with the Authority 120 days from the date of the MCE’s Notice of Appeal Resolution or where the MCE failed to meet appeal timelines (standard appeal sixteen (16) days to review and resolve appeal from date of receipt with a possible fourteen (14) day extension OAR 410-141-3890, expedited appeal 72 hours to review and resolve appeal from date of receipt with a possible fourteen (14) day extension OAR 410-141-3895), and the procedures to exercise that right;

(O) The circumstances under which an appeal process or contested case hearing can be expedited and how the Member, member representative or the member’s provider may request it. If the MCE denies a request for an expedited appeal, it shall be transferred to the standard appeal resolution timeframes;

(P) The member’s right to have benefits continue pending resolution of the appeal or contested case hearing and that continued benefits can be requested by the Member or member’s representative. The timeframes to request that benefits be continued and the circumstances under which the member may be required to pay the cost of these services as described in OAR 410-141-3910 ;

(Q) The member’s right to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member’s adverse benefit determination including any processes, strategies, or evidentiary standards used by the MCE in setting coverage limits or making the adverse benefit determination;

(R) Information on requesting help and who to contact;

(S) To support their appeal, the member’s right to give information and testimony in person or in writing, and make legal and factual arguments in person or in writing within the appeal timelines; and

(T) Inclusion of the names of providers, clinics or member’s representative copied on the notice;

(b) Use an Authority approved NOABD notice form unless the member is a dually eligible member of affiliated Medicare and Medicaid plans, in which case the CMS Integrated Denial Notice may be used as long as it incorporates required information fields in the NOABD.

(3) The following are notice requirements for post service denials:

(a) Meet the content notice requirements specified in 42 CFR § 438.404 and in the MCE contract, including the following information:

(A) MCE contact information including name, address, and telephone number and subcontractor contact information, if applicable, included in the NOABD excluding any cover pages;

(B) Date of the notice;

(D) Member’s name, D.O.B, address, and OHP member ID number;

(E) Service previously provided in plain language and the adverse benefit determination the MCE made;

(F) Date the service was provided;

(G) Name of the provider who provided the service;

(H) Effective date (date claim denied) of the adverse benefit determination if different from the date of the notice;

(I) Diagnosis and procedure codes submitted on the claim including a description of all codes in plain language. For services that do not include a procedure code a description of the service provided in plain language;

(J) Whether the MCE considered other conditions such as co-morbidity factors if the condition was below the funding line on the Prioritized List of Health Services and other services pursuant to OAR 410-141-3820 and 410-141-3830. NOABD shall clearly indicate whether a medical review was performed and if not that the provider can resubmit claim with chart notes for review of comorbidity;

(L) A reference to the specific statutes and administrative rules to the highest level of specificity for each reason and specific circumstance identified in the ABD notice;

(M) The Member, member representative or, the provider with the member’s written consent as required under OAR 410-141-3890(1), may file a written or oral appeal of the MCE’s adverse benefit determination with the MCE within 60 days from the date of the NOABD, including information on exhausting the MCE’s one level of appeal, and the procedures to exercise that right;

(N) The Member, member representative or the provider with the member’s written consent has the right to request a contested case hearing either orally or in writing with the Authority 120 days from the date of the MCE’s Notice of Appeal Resolution or where the MCE failed to meet appeal timelines (standard appeal 16 days to review and resolve appeal from date of receipt with a possible fourteen (14) day extension 410-141-3890, expedited appeal seventy two (72) hours to review and resolve appeal from date of receipt with a possible 14 day extension 410-141-3895) and the procedures to exercise that right;

(O) An explanation to the member that there are circumstances under which an appeal process or contested case hearing can be expedited and how the Member, member representative or the member’s provider may request it, but that an expedited appeal and hearing shall not be granted for post-service denials as the service has already been provided;

(R) A statement that the provider cannot bill the member for a service rendered unless the member signed an OHP Agreement to Pay form (OHP 3165 or 3166);

(S) To support their appeal, the member’s right to give information and testimony in person or in writing, and make legal and factual arguments in person or in writing within the appeal timelines;

(T) Information on requesting help and who to contact; and

(U) Inclusion of the names of providers, clinics or member’s representative copied on the notice.

(b) Use an Authority approved form unless the member is a dually eligible member of affiliated Medicare and Medicaid plans, in which case the CMS Integrated Denial Notice may be used as long as it incorporates required information fields in the NOABD.

(4) The MCE shall provide a copy of the Request to Review a Health Care Decision Appeal and Hearing Request form (OHP 3302) or approved facsimile when an NOABD is issued.

(5) The MCE may provide a copy of the Non-Discrimination Policy when an NOABD is issued.

(6) For requirements of NOABD that affect services previously authorized, the MCE shall mail the notice at least ten (10) days before the date the adverse benefit determination reduction, termination, or suspension takes effect, as referenced in 42 CFR 431.211.

(7) In 42 CFR §§ 431.213 and 431.214, exceptions related to advance notice include the following:

(a) The MCE may mail the notice no later than the date of adverse benefit determination if:

(A) The MCE has factual information confirming the death of the member;

(B) The MCE receives a signed, written notice from the member that the services previously requested are no longer desired and clearly indicates the member understands that the services previously requested shall be terminated or reduced as a result of the notice;

(C) The MCE may verify that the member has been admitted to an institution where the member is no longer eligible for OHP services from the MCE;

(D) The MCE is unaware of the member’s location and the MCE receives returned mail directed to the member from the post office indicating no forwarding address and the Authority or Department has no other address;

(E) The MCE verifies another state, territory, or commonwealth accepted the member for Medicaid services; or

(F) The member’s PCP, PCD, or behavioral health professional prescribed a change in the level of health services.

(b) The MCE must mail the notice five days before the adverse benefit determination when the MCE has:

(A) Facts indicating that an adverse benefit determination may be taken because of probable fraud on part of the member; and

(B) Verified those facts, whenever possible, through secondary resources.

(c) For denial of payment, the adverse benefit determination shall be mailed at the time of any adverse benefit determination that affects the claim.

(8) Within sixty (60) days from the date on the notice: The member or provider may file an appeal; the member may request a Contested Case Hearing with the Authority after receiving notice that the MCE’s adverse benefit determination is upheld; or if the MCE fails to adhere to the notice and timing requirements in 42 CFR 438.408, the Authority may consider the MCE appeals process exhausted.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3890 Grievances & Appeals: Appeal Process

(1) A member, member representative, or provider with the member’s written consent, may file an oral or written appeal with the Managed Care Entity (MCE) to:

(a) Express disagreement with an adverse benefit determination; or

(b) Oral appeals timeframes shall begin when there is established contact made between the member and an MCE representative. If the member leaves a voice mail message with the MCE indicating that they wish to appeal a denial the MCE shall make reasonable efforts (multiple calls at different times of day) to reach the member by phone to get the details of the service they wish to appeal. The MCE shall document each attempt to reach the member (date(s) and time(s)) by phone and make note of the date they establish contact with the member and are able to attain the appeal information needed to process the appeal.

(2) Each MCE may have only one level of appeal for members, and members shall complete the appeals process with the MCE prior to requesting a contested case hearing.

(3) For standard resolution of an appeal and notice to the affected parties, the MCE shall establish a timeframe that is no longer than 16 days from the day the MCE receives the appeal:

(a) If an MCE fails to adhere to the notice and timing requirements in 42 CFR § 438.408, the member is considered to have exhausted the MCE’s appeals process. In this case, the member may initiate a contested case hearing;

(b) The MCE may extend the timeframes from section (3) of this rule by up to 14 days if:

(A) The member requests the extension; or

(B) The MCE shows to the satisfaction of the Authority upon its request that there is need for additional information and how the delay is in the member's interest.

(A) Make reasonable efforts (including as necessary multiple calls at different times of day) to give the member prompt oral notice of the delay;

(B) Within two (2) days, give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if the member disagrees with that decision;

(C) Resolve the appeal as expeditiously as the member's health condition requires and no later than the date the extension expires.

(4) For expedited resolution of an appeal please see OAR 410-141-3895. A request for an expedited appeal for a service that has already been provided to the member (post-service) shall not be granted. The MCE shall transfer the appeal to the timeframe for standard resolution as set forth above section (3) of this rule.

(5) For purposes of this rule, an appeal includes a request from the Authority to the MCE for review of a notice.

(6) A member or the provider on the member’s behalf may request an appeal either orally or in writing directly to the MCE for any notice or failure to act within the timeframes provided in 42 CFR §438.408 (a) regarding the standard resolution of appeals by the MCE:

(a) The MCE shall ensure oral requests for appeal of a notice are treated as appeals to establish the earliest possible filing date;

(b) The member shall file the appeal with the MCE no later than 60 days from the date on the notice.

(7) Parties to the appeal include, as applicable:

(a) The member and their representative; or

(b) The legal representative of a deceased Member’s estate.

(8) The MCE shall resolve each standard appeal in time period defined above in section (4) of this rule. The MCE shall provide the member with a notice of appeal resolution as expeditiously as the member’s health condition requires, or within 72 hours for matters that meet the requirements for expedited appeals in OAR 410-141-3895.

(9) If the MCE or the Administrative Law Judge reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCE shall authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. The MCE must take the following steps:

(a) Notify the Member, the member’s representative (if applicable) both orally and in writing and the member’s provider in writing of the available services and how to access them;

(b) Enter the prior authorization into the system or adjust the encounter data claim representing the service.

(10) If the MCE or the Administrative Law Judge reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the MCE or the State shall pay for those services in accordance with the Authority policy and regulations.

(11) The written notice of appeal resolution shall be in a format approved by the Authority. The notice shall contain, as appropriate, the same elements as the notice of adverse benefit determination, as specified in OAR 410-141-3885, in addition to:

(a) The date the member filed the appeal with the MCE;

(b) The results of the resolution process and the date the MCE completed the resolution;

(d) For appeals resolved partially or wholly in favor of the member, an explanation that the member may now access those benefits that were denied and how to do so; and

(e) For appeals not resolved wholly in favor of the member:

(A) Reasons for the resolution and a reference to the particular sections of the statutes and rules involved for each reason identified in the Notice of Appeal Resolution relied upon to deny the appeal;

(B) The right to request a contested hearing or expedited hearing with the Authority and how to do so;

(D) An explanation that the member may be held liable for the cost of those benefits if the hearing decision upholds the MCE’s adverse benefit determination;

(E) Copies of the appropriate forms: Request to Review a Health Care Decision Appeal and Hearing Request form (OHP 3302) or approved facsimile.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3895 Grievances & Appeals: Expedited Appeal

(1) Each MCE shall establish and maintain an expedited review process for all oral and written appeals when the member or the provider indicates that taking the time for a standard resolution could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function as set forth in OAR 410-120-1860. Oral appeals timeframes shall begin when there is established contact made between the member and an MCE representative.

(2) The MCE shall ensure that punitive action is not taken against a provider who requests an expedited resolution.

(3) A request for an expedited appeal for a service that has already been provided (post-service) to the member will not be granted. The MCE shall transfer the appeal to the timeframe for standard resolution as set forth in 410-141-3890 (4).

(4) For expedited resolution of an appeal and notice to affected parties, the MCE shall complete the review of the expedited appeal in a timeframe that is no longer than 72 hours after the MCE receives the appeal. The MCE shall:

(a) Inform the member of the limited time available for receipt of materials or documentation for the review;

(b) Make reasonable efforts to call the member and the provider to tell them of the resolution within 72 hours after receiving the request;

(d) Extend the timeframes by up to 14 days if:

(A) The member requests the extension; or

(B) The MCE shows (to the satisfaction of the Authority upon its request) that there is need for additional information and how the delay is in the member's interest.

(e) If the MCE extends the timeframes not at the request of the member, the MCE shall:

(A) Make reasonable efforts (including as necessary multiple calls at different times of day) to give the member prompt oral notice of the delay;

(B) Within two days, give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision.

(5) If the MCE provides an expedited appeal but denies the services or items requested in the expedited appeal, the MCE shall inform the member of the right to request an expedited contested case hearing and shall send the member a Notice of Appeal Resolution, in addition to Hearing Request and Information forms as set forth in OAR 410-141-3890.

(6) If the MCE denies a request for expedited resolution on appeal, the MCE shall:

(a) Transfer the appeal to the timeframe for standard resolution in accordance with OAR 410-120-1860;

(b) Make reasonable efforts to give the member and requesting provider prompt oral notice of the denial and follow up within two days with a written notice.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3900 Grievances & Appeals: Contested Case Hearings

(1) A Managed Care Entity (MCE) shall have a system in place to ensure its members and providers acting on behalf of a member can request that the Authority review a final adverse determination by the MCE in a contested case hearing:

(a) Contested case hearings are conducted pursuant to ORS 183.411 to 183.497 and the Attorney General’s Uniform and Model Rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 to 137-003-0700. Processes for contested case hearings are provided in OAR 410-120-1860 Contested Case Hearing Procedures;

(b) If a provider filed an appeal on behalf of a member, as permitted in OAR 410-141-3890, the provider may subsequently request a contested case hearing on behalf of the member in accordance with the procedures in this rule;

(2) The member may not proceed to a hearing without first completing an appeal with their MCE and receiving written notice that the MCE adverse benefit determination is upheld, subject to the exception under section (3) of this rule, below:

(a) The member shall file a hearing request with the Authority using form OHP 3302 or any other Authority-approved hearing request form no later than 120 days from the date of the MCE’s notice of appeal resolution. The Authority shall consider the request timely with the exception as noted for expedited hearing requests in OAR 410-141-3905;

(b) If the member sends a contested case hearing request directly to the Authority and the Authority determines that the member qualifies for a contested case hearing, the MCE shall submit the required documentation to the Authority’s Hearings Unit within two (2) business days of the Authority’s request;

(c) If the member files a request for an appeal or contested case hearing with the Authority prior to the member filing an appeal with the MCE, and if the request does not satisfy section (3) below, the Authority shall transfer the request to the MCE and provide notice of the transfer to the member. The MCE shall:

(A) Review the request immediately as an appeal of the MCE’s notice of adverse benefit determination;

(B) Respond to the request for the appeal in accordance with 410-141-3890.

(d) If a member sends the contested case hearing request to the MCE after the MCE has already completed the initial plan appeal, the MCE shall:

(A) Date-stamp the hearing request with the date of receipt; and

(B) Submit the following required documentation to the Authority within two business days:

(i) A copy of the hearing request notice of adverse benefit determination, and notice of appeal resolution;

(ii) All documents and records the MCE relied upon to take its action, including those used as the basis for the initial action or the notice of appeal resolution, if applicable, and all other relevant documents and records the Authority requests as outlined in detail in OAR 141-410-3890.

(3) If, after a member properly files an appeal, the MCE fails to adhere to the notice and timing requirements in 42 CFR § 438.408, the Authority may consider the member to have exhausted the MCE’s appeals process for purposes of requesting a contested case hearing, as provided in OAR 410-141-3890(3). The Authority shall notify the MCE of the Authority’s decision to allow the member access to a contested case hearing.

(4) Effective February 1, 2012, the method described in OAR 137-003-0520(8)-(10) is used in computing any period of time prescribed in OAR chapter 410, divisions 120 and 141 applicable to timely filing of requests for hearing. However, due to operational conflicts, the procedures needing revision, and the expense of doing so, the provisions in OAR 137-003-0520(9) and 137-003-0528(2) that allow hearing requests to be treated as timely based on the date of postmark do not apply to MCE member contested case hearing requests.

(5) The parties to a contested case hearing include, as applicable:

(a) The member and their representative; or

(b) The legal representative of a deceased Member’s estate; and

(6) The Authority shall refer the hearing request along with the notice of adverse benefit determination or notice of appeal resolution to the Office of Administrative Hearings (OAH) for hearing. Contested case hearings are requested using Authority form MSC 443 or other Authority-approved appeal or hearing request forms.

(7) The Authority shall issue a final order or otherwise resolve the case ordinarily within ninety (90) days from the date the MCE receives the member’s request for appeal. The ninety (90) day count does not include the days between the date the MCE issued a notice of appeal resolution and the date the member filed a contested case hearing request. The Authority must issue the final order within this time frame except in unusual circumstances, documented in the member’s record, when:

(a) The agency cannot reach a decision because the member requests a delay or fails to take a required action; or

(b) There is an administrative or other emergency beyond the Authority's control.

(8) For reversed hearing resolution services:

(a) For services not furnished while the appeal or hearing is pending. If the Administrative Law Judge reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCE shall authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. The MCE must take the following steps:

(A) notify the Member, the member’s representative (if applicable) both orally and in writing and the member’s provider in writing of the available services and how to access them;

(B) Enter the prior authorization into the system or adjust the encounter data claim representing the service.

(b) For services furnished while the appeal or hearing is pending. If the Administrative Law Judge reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the MCE or the State shall pay for those services in accordance with the Authority policy and regulations.

(c) Any party to the hearing can file written exceptions or present argument to the Proposed and Final Order within ten working days after the date the Proposed Order is issued by the ALJ (see OAR 410-120-1860). If written exceptions are filed the Order does not become a Final Order on the 11th work day and the services shall not be provided until the Final Order is issued by OHA. Once a Final Order is issued and if the decision remains overturned the services shall be authorized or provided to the member within 72 hours of the MCE receiving the Final Order.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570 - 414.686
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3905 Grievances & Appeals: Expedited Contested Case Hearings

(1) An MCE shall have a system in place to ensure its members and providers have access to expedited review for MCE’s action by requesting an expedited contested case hearing. Contested case hearings are conducted pursuant to ORS 183.411 to 183.497 and the Attorney General’s Uniform and Model Rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 to 137-003-0700. Processes for expedited contested case hearings are provided in OAR 410-120-1860 Contested Case Hearing Procedures.

(2) A member or provider who believes that taking the time for a standard resolution of a request for a contested case hearing could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function may request an expedited contested case hearing.

(3) A request for an expedited hearing for a service that has already been provided (post-service) to the member will not be granted.

(4) The member may not request an expedited contested case hearing without first completing an appeal or expedited appeal with the MCE, subject to the exception in OAR 410-141-3900(3). When a member files a hearing request prior to completion of an MCE appeal or expedited appeal, the Authority shall follow procedures set forth in OAR 410-141-3900.

(5) Expedited hearings are requested using Authority form MSC 443 or other Authority-approved appeal or hearing request forms.

(6) The MCE shall submit relevant documentation to the Authority within two working days. The Authority shall decide within two working days from the date of receiving the relevant documentation whether the member is entitled to an expedited contested case hearing.

(7) If the Authority denies a request for an expedited contested case hearing, the Authority shall:

(a) Handle the request for a contested case hearing in accordance with OAR 410-120-1860; and

(b) Make reasonable efforts to give the member prompt oral notice of the denial and follow up within two days with a written notice.

(8) If a member requests an expedited hearing, the Authority shall request documentation from the MCE, and the MCE shall submit relevant documentation including clinical documentation to the Authority within two working days.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3910 Grievances & Appeals: Continuation of Benefits

(1) A member who may be entitled to continuing benefits may request and receive continuing benefits in the same manner and same amount while an appeal or contested case hearing is pending:

(a) A member can request continuation of benefits by phone, letter, fax or by using the Review of Health Care Decision form and check the box requesting continuing benefits by:

(A) The tenth day following the date of the notice of adverse benefit determination or the notice of appeal resolution; or

(B) The effective date of the action proposed in the notice, if applicable.

(b) In determining timeliness, delay for good cause as defined in OAR 137-003-0528 is not counted;

(A) The appeal involves the termination, suspension, or reduction of previously authorized services;

(B) The services were ordered by an authorized provider;

(D) The member timely files for continuation of benefits.

(d) If, at the member’s request, the MCE continues or reinstates benefits while the appeal or hearing is pending, the benefits must be continued until one of the following occurs:

(A) The member fails to request a hearing and continuation of benefits within 10 calendar days after the date of the notice of appeal resolution;

(B) The member withdraws the appeal or request for hearing;

(e) Member responsibility for services furnished while the appeal or hearing is pending. If the final resolution of the appeal or hearing is adverse to the member, that is, upholds the MCE’s adverse benefit determination, the MCE may recover the cost of services furnished to the member while the appeal and hearing was pending, to the extent that they were furnished solely because of the requirements of this section.

(2) For reversed appeal and hearing resolution services:

(a) Benefits not furnished while the appeal or hearing is pending. If the MCE or the Administrative Law Judge reverses a decision to deny, limit, or delay services that were not furnished while the appeal/hearing was pending, the MCE shall authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. The MCE must take the following steps:

(A) notify the member, the member’s representative (if applicable) both orally and in writing and the member’s provider in writing of the available services and how to access them;

(B) Enter the prior authorization into the system or adjust the encounter data claim representing the service.

(b) Benefits furnished while the appeal or hearing is pending. If the MCE or the Administrative Law Judge reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the MCE or the Authority shall pay for those services in accordance with the Authority policy and regulations.

History

Statutory/Other Authority: ORS 413.032, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3915 Grievances & Appeals: System Recordkeeping

(1) Each MCE shall maintain records of grievances, appeals, Notices of Adverse Benefit Determinations (NOABDs) and prior authorizations and shall review the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the state quality strategy as stated in 42 CFR 438.416 and in alignment with contractual requirements.

(2) Consistent with record retention requirements in OAR 410-141-3520, MCEs must maintain yearly logs of all appeals, grievances, NOABDs and prior authorizations for 10 years, which must include information about the reasons for each grievance, appeal, NOABD and prior authorization denial, as well as the resolution and supporting reasoning.

(3) The MCE must review the log monthly for completeness, accuracy, and compliance with required procedures.

(4) MCEs shall submit for the Authority’s review the Grievance and Appeals Log, samples of NOABDs, prior authorization documentation and other reports as required under the MCE contract.

(5) The Grievance System Report and Grievance and Appeals Log shall be forwarded to the MCE’s Quality Improvement committee to comply with the Quality Improvement standards as follows:

(a) Review of completeness, accuracy, and timeliness of documentation;

(b) Compliance with written procedures for receipt, disposition, and documentation; and

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3920 Transportation: NEMT General Requirements

(1) For definitions of terms used in 410-141-3920 to 410-141-3965, please see OAR 141-136-3000.

(2) A Coordinated Care Organization (CCO) shall provide all non-emergency medical transportation (NEMT) services for its members. For purposes of OAR 410-141-3920 to 410-141-3965, references to a “member” include any individual eligible for NEMT services under section (2) of this rule unless context dictates otherwise:

(a) The CCO is responsible for NEMT services for all of its members’ health care services consistent with the covered services described in OAR 410-141-3820 and the excluded services and limitations described in OAR 410-141-3825 and (2)(b) and (2)(c) of this rule;

(b) NEMT services for those health care services that, based on the member’s plan type, are paid by the Authority’s fee-for-service program and that, based on rule or contract, are carved-out from or otherwise not covered by the CCO and provided by the Authority;

(d) NEMT must not provide transportation services, including public transportation, mileage reimbursement or driver provided rides, to an emergency room or emergency department setting for medical services that are not pre-scheduled, including from urgent care clinics;

(e) For members enrolled in the Compact of Free Association (COFA) Dental Program or the Veteran Dental Program, both of which are defined in OAR chapter 410, division 200, the CCO is responsible only for NEMT services related to the member’s dental services.

(3) A CCO shall provide a toll-free call center for members to request rides.

(a) The CCO shall ensure that its call center operates, at a minimum, Monday through Friday from 9:00 a.m. to 5:00 p.m. The CCO may close its call center on New Year’s Day, Memorial Day, July 4th, Labor Day, Thanksgiving, and Christmas. The Authority may approve, in writing, additional days of closure if the CCO requests the closure at least thirty (30) days in advance.

(b) Consistent with OAR 410-141-3505, a CCO may subcontract the operation of its call center. If the CCO’s subcontractor is also contracted by the Authority as an NEMT brokerage for FFS members, the CCO remains fully accountable for the performance of the subcontracted work related to the CCO contract.

(4) Neither a CCO nor any of its Subcontracted transportation providers may bill a member for transport to or from covered medical services, even if the CCO or its contracted transportation provider denied reimbursement for the transportation services.

(5) Transportation providers shall be considered “participating providers” for the purposes of OAR 410-141-3520 (Record Keeping and Use of Health Information Technology).

(6) A CCO shall have written policies and procedures regarding its NEMT services. All policies and procedures must be provided to all Members either in Contractor’s Member Handbook or in a stand-alone document referred to as a “NEMT rider guide” that meets the delivery and content specifications as defined by the Authority. The CCO’s written policies and procedures regarding NEMT services shall provide, without limitation, for the following:

(a) Allow members or their representatives to schedule:

(A) NEMT services up to 90 days in advance;

(B) Multiple NEMT services at one time for recurring appointments up to 90 days in advance; and

(b) Comply with the following criteria for member drop-offs and pick-up protocols. Drivers are not permitted to:

(A) Drop Members off at an appointment more than 15 minutes prior to the office or other facility opening for business unless requested by the member or, as applicable, the Member’s guardian, parent, or representative; and

(B) Pick up Members from an appointment more than 15 minutes after the office or facility closes for business unless the appointment is not reasonably expected to end within 15 minutes after closing, or as requested by the member, or as applicable, the Member’s guardian, parent, or representative.

(c) Describe passenger rights and responsibilities as set forth in 42 CFR §438.210, and as set forth in OARs 410-141-3920 through 410-141-3960, and other state and federal administrative statutes and rules relating to the rights and responsibilities of Medicaid recipients such as the right to file a grievance and request an appeal or reconsideration.

(7) A CCO or brokerage must review a requested NEMT ride service authorization in the following manner:

(a) When providing notification to the member or member representative of an approval, denial or cancellation of the member’s requested ride service it must occur by their preferred method of contact.

(A) If approving the NEMT ride service request, notification of the applicable transportation arrangements shall occur prior to the time of the service or no less than 48 hours prior to the time of the service. This timeframe shall be reduced if the request for a ride service occurs close to the scheduled ride service time to ensure the member is informed of the approved requested service;

(B) If denying a request for an NEMT ride service the CCO or NEMT brokerage must provide:

(i) A secondary review by another employee with knowledge of NEMT service requirements, prior to determination of a denial;

(ii) Notification to the member or member representative. Notification must occur prior to sending a notice of adverse benefit determination (NOABD) and at least 48 hours prior to the time of the requested ride service. This timeframe shall be reduced if the request for a ride service occurs close to the scheduled ride service time to ensure the member is informed of the denied requested service;

(iii) The member with a mailed NOABD within 72 hours of denial determination;

(C) If canceling a previously approved NEMT ride service request (e.g., due to adverse weather conditions), the CCO or NEMT brokerage must provide notification to the member or the member’s representative prior to the time that the ride service was to occur or as soon as practical.

(b) Adhering to the grievance and appeal processes and rights specified in OAR 410-141-3835 through 410-141-3915 available with respect to NEMT services.

(8) This rule applies only to the Authority’s pilot project in effect for 2/16/2024 through 2/15/2025, which allows a CCO to utilize a Transportation Network Company (TNC) to provide NEMT services to the CCO’s members.

(a) Transportation network company (TNC) has the meaning found in ORS 742.520.

(b) A TNC must obtain a certification from the Oregon Health Authority to participate in the TNC Pilot Program as an NEMT provider. Certification for the TNC pilot program is obtained by submitting to HSD.QualityAssurance@odhsoha.oregon.gov the following documents:

(A) A document that identifies the process or policies the TNC follows and documents its compliance with the requirement that each driver has a valid driver license. The TNC must maintain records of their drivers participating in the TNC Pilot and share relevant information with OHA when requested;

(B) A document that identifies the processes or policies the TNC follows and documents its compliance with the processes and policies, to ensure that proposed TNC pilot program drivers, employees, agents and contractors are not, as described in 42 CFR §438.610 (a) or (b): Excluded, suspended, or debarred, or otherwise excluded from participating in procurement or non-procurement activities under the Federal Acquisition Regulations or federal Executive Order No. 12549 or the implementation guidelines for federal Executive Order No. 12549; or Excluded from participation in any federal health care program under section 1128 or 1128A of the Social Security Act as described in 42 CFR 438.610;

(C) A document that identifies the process or policies that the TNC follows and documents its compliance with the processes and policies, to ensure that all TNC proposed pilot program drivers have not: committed more than three (3) traffic violations under ORS 801.557 in the past three (3) years; or committed one (1) or more traffic crimes under ORS 801.545 within the past seven (7) years; or have been convicted of Driving Under the Influence of Intoxicants under ORS 813.010 within the last seven (7) years;

(D) The TNC’s policy for monitoring the driving records and criminal records of all of its proposed TNC pilot program drivers, employees, agents, and contractors;

(E) The TNC’s policy for compliance with federal and state regulatory requirements to ensure all OHP member information is protected in accordance with OAR 410-136-3280;

(F) Proof of insurance and policy compliant with ORS 742.520(1)(b).

(c) Upon receipt of the documents identified in subsection (b) of this rule, the application shall be reviewed and if all requirements are met, then the Authority shall issue a certificate of approval to participate in the TNC Pilot Program.

(A) Once certification is issued, a TNC certified to participate in the TNC Pilot Program shall be eligible to provide rides to OHP Members upon request from the Authority or a CCO;

(B) Rides authorized to be provided by a driver employed by or contracted with a certified TNC Pilot Program may only be utilized by a CCO or the Authority if:

(i) No NEMT driver who meets the requirements identified in OAR 410-136-3040 (NEMT Driver) accepts an NEMT brokerage request within 24 hours of the scheduled ride time; or

(ii) A previously scheduled NEMT Driver cancels the assigned ride within 24 hours of the scheduled ride time and no other NEMT Driver accepts, within a reasonable period of time, the brokerage’s new request for another NEMT Driver; or

(iii) The previously scheduled NEMT Driver does not arrive at the pick-up location within 15 minutes after the scheduled pick-up time.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625, 414.572, 414.605, 414.665 & 414.719
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 130-2024, amend filed 10/24/2024, effective 11/01/2024
DMAP 75-2024, amend filed 03/13/2024, effective 03/13/2024
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3925 Transportation: Vehicle Equipment and Driver Standards

(1) This rule does not apply to ambulance providers, ambulance vehicles, or ambulance personnel that are licensed and regulated by ORS Chapter 682 and OAR chapter 333, divisions 250, 255, 260 and 265, whether providing ambulance or stretcher transports.

(2) The CCO shall require all vehicles used for NEMT services to meet the following requirements for the comfort and safety of the members:

(a) The interior of the vehicle shall be clean and free from any debris impeding a member’s ability to ride comfortably;

(b) Smoking, aerosolizing or vaporizing of inhalants is prohibited in the vehicle at all times in accordance with ORS 433.835 to 433.990 and OAR 333-015-0025 to 333-015-0090; and

(c) Compliance with all applicable local, state, and federal transportation laws regarding vehicle and passenger safety standards and comfort. All vehicles shall include, without limitation, the following safety equipment:

(A) Safety belts for all passengers if the vehicle is legally required to provide safety belts;

(B) First aid kit;

(D) Roadside reflective or warning devices;

(E) Flashlight;

(F) Tire traction devices when appropriate;

(G) Disposable gloves; and

(H) All equipment necessary to securely transport members using wheelchairs or stretchers in accordance with the Americans with Disabilities Act of 1990 (as amended) (ADA), Section 504 of the Rehabilitation Act of 1973, and Oregon Revised Statute 659A.103.

(3) A preventative maintenance schedule shall be followed for each vehicle that incorporates at least all of the maintenance recommended by the vehicle manufacturer. The vehicle must be in good operating condition and shall include, but is not limited to, the following equipment:

(a) Side and rearview mirrors;

(b) Horn;

(d) Working turn signals, headlights, taillights, and windshield wipers.

(4) Prior to hiring an NEMT driver, the CCO shall require the following:

(a) The driver must have a valid driver license. The license must be the class of license with any required endorsements that permits the driver to legally operate the vehicle for which they are hired to drive pursuant to ORS chapter 807 and OAR chapter 735, division 062, or the applicable statutes of other states;

(b) The driver shall not be included on the exclusion list maintained by the Office of the Inspector General; and

(c) The driver must pass a criminal background check in accordance with ORS 181A.195 and 181A.200, and OAR chapter 257, division 10. If the driver is employed by a mass transit district formed under ORS Chapter 267, the driver must pass a criminal background check in accordance with ORS 267.237 as well as the mass transit district’s background check policies. A CCO shall have an exception process to the criminal background check requirement that may allow approval of a driver with a criminal background under certain circumstances. The exception process must include review and consideration of when the crime occurred, the nature of the offense, and any other circumstances to ensure that the member is not at risk of harm from the driver. Any approvals made through the exception process must be documented and maintained for 10 calendar years, even if the CCO is no longer a Medicaid enrolled provider before the end of the three years. The Authority may request this information at any time during the three-year retention period;

(d) Pursuant to the Consolidated Appropriations Act, 2021, Division CC, Title II, Section 209 drivers must disclose to the CCO or its Subcontracted transportation provider any violation of a state drug law and his or her driving history, including any traffic violations.

(5) Drivers authorized to provide NEMT services must receive training on their job duties and responsibilities including:

(a) Understanding NEMT services in general, reporting forms, vehicle operation, requirements for fraud and abuse reporting, and the geographic area in which drivers will provide service;

(b) Completing the National Safety Council Defensive Driving course or equivalent within three months of the date of hire and at least every three years thereafter;

(c) Completing and maintaining certification for Red Cross-approved First Aid, Cardiopulmonary Resuscitation, and blood spill procedures courses or equivalent prior to driving any members;

(d) Completing the Passenger Service and Safety course or equivalent course within three months of the date of hire and at least every three years thereafter;

(e) Understanding the CCO’s established procedures for responding to a member’s needs for emergency care should they arise during the ride; and

(f) Understanding of and compliance with all state driving and transportation laws.

(g) Pursuant to the Consolidated Appropriations Act, 2021, Division CC, Title II, Section 209, drivers must disclose to the CCO (or its Subcontracted transportation provider) any violation of a state drug law and any changes in his or her driving history, including any traffic violations.

(6) Emergency Medical Technicians (EMT) licensed under OAR Chapter 333, Division 265 may be hired as an NEMT driver provided the CCO:

(a) Verifies the individual’s EMT license is current, is in good standing with the Authority, and then re-verifies the license annually;

(b) Verifies the EMT is not on the exclusion list maintained by the Office of the Inspector General;

(d) Conducts its own criminal background check on the EMT in accordance with section (4)(c) of this rule; and

(e) Completes the training required under subsection (5)(a) of this rule.

(7) For authorized out-of-state NEMT services in which the transportation provider solely performs work in the other state and for which the CCO has no oversight authority, the CCO is not responsible for requiring that the subcontractor’s vehicle and standards meet the requirements set forth in this rule.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3930 Transportation: Out-of-Service Area and Out-of-State Transportation

(1) A CCO shall provide NEMT services outside the CCO’s service area under any and all of the following circumstances:

(a) The member is receiving covered services that are not available, in accordance with OAR 410-141-3515, in the CCO’s service area;

(b) The member is receiving covered services outside of Oregon, but the location is contiguous to the CCO’s service area and no more than 75 miles from the Oregon border;

(c) The member is receiving in-patient services at a facility outside the CCO’s service area due to unavailability within the CCO’s service area and the member requires additional covered services within the service area where the inpatient service facility is located; and

(d) The member is receiving covered services outside the State of Oregon because the required covered service is not available within Oregon.

(2) Nothing in this rule prohibits a CCO from providing and paying for NEMT services to allow a client to access other services the CCO authorizes.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3935 Transportation: Attendants for Child and Special Needs Transports

(1) This rule applies to NEMT for children 12 years of age and under who are eligible for NEMT services to and from OHP-covered medical services. The rule also applies to members with special physical or developmental needs regardless of age.

(2) Parents or guardians must provide an attendant to accompany these members while traveling to and from covered services and other purposes authorized by the CCO in accordance with OAR 410-141-3930(2) except when:

(a) The driver is a Department of Human Services (Department) volunteer or employee or an Authority employee;

(b) The member requires secured transport pursuant to OAR 410-141-3940 (Secured Transports); or

(c) An ambulance provider transports the member for non-emergent services, and the CCO reimburses the ambulance provider at the ambulance transport rate, per CCO contract or non-contracted rate policy.

(3) NEMT ambulance transports shall have an attendant when the CCO uses an ambulance to provide wheelchair or stretcher car or van rides.

(4) The Department shall establish and administer written guidelines for members in the Department’s custody including written guidelines for volunteer drivers. If the Department’s requirements or administrative rules differ from this rule, the Department’s requirements or administrative rules take precedence.

(5) An attendant may be the member’s mother, father, stepmother, stepfather, grandparent, or guardian. The attendant may also be any adult 18 years or older authorized by the member’s parent or guardian.

(6) CCOs shall have the right to require the member’s parent or guardian to provide written authorization for an attendant other than the parent or guardian to accompany the member.

(7) Neither the CCO nor its subcontractor shall bill additional charges for a member’s attendant.

(8) For members who are 12 years or younger or members who have additional needs, an adult attendant must be present for all trips.

(9) The member’s parent, guardian, or adult caregiver shall provide and install safety seats as required by ORS 811.210–811.225. An NEMT driver must not transport a member if a parent or guardian fails to provide a safety seat that complies with state law.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3940 Transportation: Secured Transports

(1) “Secured transport” means NEMT services for the involuntary transport of members who are in danger of harming themselves or others. Secured transports may be used when:

(a) The CCO verified that the secured transporter has met the requirements of the secured transport protocol pursuant to OAR 309-033-0200 through 309-033-0970, and the secured transporter is able to transport the member who is in crisis or at immediate risk of harming themselves or others due to mental or emotional problems or substance abuse; and

(b) The transport is to a Medicaid enrolled facility that the Authority recognizes as being able to treat the immediate medical or behavioral health care needs of the member in crisis.

(2) One additional attendant may accompany the member at no additional charge when medically appropriate, such as to administer medications in-route or to satisfy legal requirements including, but not limited to, when a parent, legal guardian, or escort is required during transport.

(3) The CCO shall authorize transports to and from OHP covered medical services for an eligible member for court ordered medical services with the following exceptions:

(a) The member is in the custody of or under the legal jurisdiction of any law enforcement agency;

(b) The member is an inmate of a public institution as defined in OAR 461-135-0950 (Eligibility for Inmates); or

(4) The CCO shall assume that a member returning to their place of residence is no longer in crisis or at immediate risk of harming themselves or others, and is, therefore, able to use non-secured transportation. In the event that a secured transport is medically appropriate to return a member to their place of residence, the CCO shall obtain written documentation signed by the treating medical professional stating the circumstances that required secured transport. The CCO shall retain the documentation and a copy of the order in their record for the Authority to review.

(5) The CCO may approve and pay for secured medical transport provided to a person going to or from a court hearing or to or from a commitment hearing if there is no other source of funding for this transport.

(6) This rule does not apply to ambulance providers, ambulance vehicles, or ambulance personnel that are licensed and regulated by ORS chapter 682 and OAR chapter 333, divisions 250, 255, 260 and 265, whether providing ambulance or stretcher transports.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3945 Transportation: Ground and Air Ambulance Transports

(1) Transporting a member via ambulance is required when a medical facility or provider states the member’s medical condition requires the presence of a health care professional during the emergency or non-emergency transport. This includes neonatal transports.

(2) For NEMT services, the CCOs shall authorize the transport.

(3) CCOs shall provide ambulance transports with a medical technician when:

(a) A member’s medical condition requires a stretcher and the length of transport requires a personal care attendant, but the member does not have one; or

(b) Necessitated by the member’s medical condition consistent with section (1) above of this rule.

(4) When a member’s medical condition is an emergency as defined in OAR 410-120-0000, emergency ambulance transportation must be used. The ambulance must transport the member to the nearest appropriate facility able to meet the member's medical needs.

(5) CCOs shall verify that providers of ground or air ambulance services have been licensed by the Authority to operate ground or air ambulances. If the ambulance service provider is located in a contiguous state and regularly provides rides to OHP members, the CCO must ensure the ambulance service provider has been licensed by both the Authority and the contiguous state in which it is operating.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3955 Transportation: Member Service Modifications and Rights

(1) For the purposes of this rule, “direct threat” means a significant risk to the health or safety of others and which:

(a) Cannot be eliminated or reduced to an acceptable level through the provision of auxiliary aids and services or through reasonably modifying policies, practices, or processes; and

(b) Is identified through an individual assessment that relies on current medical evidence or the best available objective evidence which shows:

(A) The nature, duration, and severity of the risk;

(B) The probability that a potential injury will actually occur; and

(2) CCOs shall draft policies and procedures that ensure the safety of all passengers in NEMT vehicles which shall include, without limitation, policies and procedures that comply with this rule. CCOs shall provide its passenger safety policy and procedures to its NEMT subcontractors and require the NEMT subcontractors to implement and follow such policies and procedures. The CCOs’ passenger safety policy and procedures shall be included in their member handbooks and posted on their websites.

(3) CCOs and their subcontractors shall comply with the Authority’s non-discrimination and modification rules found at OAR 943-005-0000 to 943-005-0070.

(4) CCOs must not apply criteria, standards, or practices that screen out, or tend to screen out, individuals in a protected class, as defined under state anti-discrimination laws, from fully and equally enjoying any goods, services, programs, or activities unless:

(a) The criteria can be shown to be necessary for providing those goods and services; or

(b) The CCO determines the screening or exclusion identifies a direct threat to the health and safety of others.

(5) A CCO may modify NEMT services when the member:

(a) Threatens harm to the driver or others in the vehicle;

(b) Presents a direct threat to the driver or others in the vehicle;

(d) Engages in behavior that, in the CCO’s judgment, causes local medical providers or facilities to refuse to provide further services without modifying NEMT services;

(e) Frequently does not show up for scheduled rides;

(f) Exhibits chronic lateness, defined as being more than 15 minutes late after the driver arrives (within the pickup window) for 25 percent or more of those trips occurring within the previous three-months; or

(g) Frequently cancels the ride on the day of the scheduled ride time.

(6) A member may request modification of NEMT services when the NEMT driver:

(a) Threatens to harm the member or others in the vehicle;

(b) Drives or engages in other behavior that places the member or others in the vehicle at risk of harm; or

(7) Reasonable modifications include, but are not limited to, requiring members to:

(a) Use a specific transportation provider;

(b) Travel with an attendant;

(d) Drive or locate someone to drive the member and receive mileage reimbursement; and

(e) Confirm the ride with the NEMT brokerage/subcontractor on the day of or the day before the scheduled ride.

(8) When the NEMT brokerage determines a need for a service modification, they shall notify the member using the member’s preferred method of notification. NEMT brokerages must make three (3) separate reasonable attempts to notify the member. This shall be followed by written confirmation to the member, the member’s care coordinator, and any requesting provider. Before modifying services, the NEMT brokerage/subcontractor, a CCO representative, and the member shall:

(a) Communicate about the reason for imposing a modification;

(b) Explore options that are appropriate to the member’s needs; and

(9) The communications discussed in section (8) of this rule may include:

(a) The member’s care team, including any care coordinator, at the request or upon approval of the member or the CCO;

(b) Any other individual of the member’s choosing.

(10) Responses to requests for modification or auxiliary aids based on disability or other protected class status under state or federal rule or law must comply with the Americans with Disabilities Act and all other applicable state and federal laws and rules.

(11) A CCO must not modify NEMT services unless the modification is permitted under this rule or required in order to accommodate a disability requiring modification or auxiliary aid.

(12) A CCO must not modify NEMT services to result in a denial of NEMT services to a member.

(13) A CCO shall make all reasonable efforts to offer an appropriate alternative to meet a member’s needs under the circumstances.

History

Statutory/Other Authority: ORS 413.042 & 414.572
Statutes/Other Implemented: ORS 414.572
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3960 Transportation: Member Reimbursed Mileage, Meals, and Lodging

(1) A Coordinated Care Organization (CCO) may prior authorize a member’s mileage, meals, and lodging to covered medical service in order for the member to qualify for reimbursement.

(2) A CCO shall disallow a client reimbursement request received more than 45 days after the travel.

(3) A CCO shall reimburse a member for mileage, meals, and lodging at rates not less than the Authority’s allowable rates. The Oregon Health Authority’s reimbursement rates are available by published memo on the Medical Transportation Services Program section of the Authority’s website.

(4) The member must return any documentation a CCO requires before receiving reimbursement. Documentation may include, but is not limited to:

(a) Receipts;

(b) Lodging invoices;

(d) An appointment verification form.

(5) A member must be reimbursed within 14 days after verifying the member’s attendance of the appointment or after the CCO receives the reimbursement request form, if required.

(a) A CCO may hold reimbursements under the amount of $10 until the member’s reimbursement reaches $10;

(b) If the member reimbursement request is submitted before 45 days from the date of transport, but is incomplete, the CCO shall take up to an additional 14 calendar days to assist the member in completing the submission. Denial must not take place while the CCO is assisting a member with an incomplete request;

(c) A CCO must issue the member a Notice of Adverse Benefit Determination, in accordance with requirements in OAR 410-141-3885, within 14 calendar days of the denial of a member reimbursement.

(6) A CCO shall reimburse members for meals when a member travels:

(a) For a minimum of four (4) hours round-trip; and

(b) The travel time must span the following meal times:

(A) For a breakfast allowance, the travel must begin before 6:00 a.m.;

(B) For a lunch allowance, the travel must span the entire period from 11:30 a.m. through 1:30 p.m.; and

(D) Travel time is considered to be time spent traveling to or from an appointment, it does not include time spent in or waiting for the appointment.

(7) A CCO’s brokerage or other transportation subcontractor shall reimburse members for lodging when:

(a) A member would otherwise be required to begin travel before 5:00 a.m. in order to reach a scheduled appointment; or

(b) Travel from a scheduled appointment would end after 9:00 p.m.; or

(8) A CCO may reimburse members for lodging under additional circumstances at the CCO’s discretion.

(9) A CCO shall reimburse for meals or lodging for one attendant, which may be a parent, to accompany the member if medically necessary, if:

(a) The member is a minor child and unable to travel without an attendant;

(b) The member's attending physician provides a signed statement indicating the reason an attendant must travel with the member;

(d) The member is or would be unable to return home without assistance after the treatment or service.

(10) A CCO may reimburse members for meals or lodging for additional attendants or under additional circumstances at the CCO’s discretion.

(11) A CCO may recover overpayments made to a member. Overpayments occur when a CCO’s brokerage or other transportation subcontractor paid the member:

(a) For mileage, meals, and lodging, and another resource also paid:

(A) The member; or

(B) The ride, meal, or lodging provider directly.

(b) Directly to travel to medical appointments, and the member did not use the money for that purpose, did not attend the appointment, or shared the ride with another member whom the brokerage also paid directly;

(c) For common carrier or public transportation tickets or passes, and the member sold or otherwise transferred the tickets or passes to another individual.

(12) If an individual or entity other than the member or the minor member’s parent or guardian provides the ride, a CCO’s brokerage or other transportation subcontractor may reimburse the individual or entity that provided the ride.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
DMAP 28-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-3965 Reports and Documentation

(1) CCOs shall maintain documentation of rides denied and rides provided to members.

(2) The CCO shall retain the documentation on NEMT service denials for 10 calendar years, even if the CCO, its brokerage, or subcontractor that denied the service is no longer a Medicaid enrolled provider before the end of the 10 years. The Authority may request this information at any time during the 10-year retention period.

(3) The Authority may request and the CCO shall provide other reports or information not specified in this rule.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020

Or. Admin. R. 410-141-5000 FINANCIAL SOLVENCY REGULATION: Definitions

When used and not otherwise defined in OAR 410-141-5005 through OAR-141-5380, the following terms shall have the meaning given in this section:

(1) “AICPA” means the American Institute of Certified Public Accountants.

(2) “Assumption Reinsurance Agreement” means a contract that:

(a) Transfers obligations or risks of existing or in-force Member Contracts from a cedent CCO to a reinsurer that acquires the obligations or risks from the cedent; and

(b) Is intended to affect a novation of the transferred Member Contracts with the result that the reinsurer becomes directly liable to the Members of the cedent CCO and the cedent CCO’s contract obligations to the Members are extinguished.

(3) “Board” means the board of directors or other equivalent governing body of a company that is vested by the company’s organizational document(s) with responsibility and authority for the governance and overall management of the affairs of the company, irrespective of the name by which the governing body or the members of that governing body are designated, except that:

(a) An individual or a group of individuals is not the board of directors because of powers delegated to the individual or group by provisions in the articles of incorporation or other equivalent organizational documents authorizing the individual or group to exercise some or all of the powers which would otherwise be exercised by a board; and

(b) A coordinated care organization may have a governing body as required by ORS 414.572 (2)(o) that is not the board of the CCO entity.

(4) “Capitated Subcontractor” means a third-party provider that enters into a Sub-capitation Arrangement with a CCO for any portion of the health care services covered by the CCO’s agreement with the Authority.

(5) “CCO Contract” means the CCO’s agreement to provide managed health care services to a Member pursuant to the CCO’s contract with the Authority.

(6) “CGAD Report” means the corporate governance annual disclosure report described at OAR 410-141-5045.

(7) “DCBS” means the Department of Consumer and Business Services.

(8) “Delinquency proceeding” means any proceeding commenced against a CCO for the purpose of liquidating, rehabilitating or conserving the CCO.

(9) “Director” means, as the context requires;

(a) A member of the board of directors or other equivalent governing body of a company that is vested by the company’s organizational document(s) with the responsibility and authority for the governance and overall management of the affairs of the company; or

(b) The Director of the Authority.

(10) “Impaired” with respect to a CCO means that the CCO’s allowed assets do not exceed its liabilities plus its required capitalization.

(11) “Loss Protection Program” means a program or set of arrangements a CCO maintains that are designed to protect the CCO against catastrophic and unexpected loss or expenses related to capitated services the CCO is obligated to provide to its Members.

(12) “Member” means an individual covered by, and entitled to, managed health care services under a CCO’s contract with the Authority.

(13) “NAIC” means the National Association of Insurance Commissioners.

(14) “NAIC Forms and Instructions” means the financial statement blanks, forms and instructions for health insurers as published and as revised by the NAIC from time to time and identified by the Authority to be applicable for the reporting period. The applicable NAIC Forms and Instructions prescribed by the Director referred to in this rule are available for inspection at the office of the Authority. Any person interested in inspecting the NAIC Forms and Instructions may contact the Authority at actuarial.services@dhsoha.state.or.us.

(15) “Qualified United States Financial Institution” means an institution that:

(a) Is organized, or, in the case of a United States branch or agency office of a foreign banking organization, is licensed, under the laws of the United States or any state thereof and has been granted authority to operate with fiduciary powers; and

(b) Is regulated, supervised and examined by federal or state authorities having regulatory authority over banks and trust companies.

(16) “Political subdivision” means, consistent with ORS 192.005, any city, county, district or any other municipal or public corporation in the State of Oregon.

(17) “Primary Reserve” means the primary Restricted Reserve Fund required by OAR 410-141-5185.

(18) “Receiver” means a receiver, rehabilitator, liquidator or conservator, as the CCO Contract may require.

(19) “Restricted Reserve Account” means the reserve account required by OAR 410-141-5185.

(20) “Restricted Reserve Funds” means the funds required to be deposited and maintained in the Restricted Reserve Account under OAR 410-141-5185.

(21) “Restricted Reserve” means the Restricted Reserve Account, the Primary Reserve, the Secondary Reserve and the Restricted Reserve Funds required by OAR 410-141-5185.

(22) “Secondary Reserve” means the secondary Restricted Reserve Fund required by OAR 410-141-5185.

(23) “Statutory Accounting Principles” means generally accepted statutory accounting principles for health insurers as prescribed, adopted or otherwise approved by DCBS for the financial and solvency regulation of health insurers under Oregon law, as supplemented by generally accepted statutory accounting principles prescribed, adopted or otherwise approved by the NAIC, including without limitation, those accounting practices, principles and procedures set forth in the NAIC’s Accounting Practices and Procedures Manual.

(24) “Sub-Capitated Arrangement” means a contract or other arrangement between the CCO and a Sub-Capitated Counterparty under which the Sub-Capitated Counterparty agrees to provide, as subcontractor to the CCO, certain of the health care services required of the CCO under its CCO Contract in return for a fixed capitation payment, the effect of which is to transfer claim frequency and utilization risk to the third-party provider.

(25) “Sub-Capitated Counterparty” means the third-party provider under a Sub-Capitated Arrangement with a CCO.

(26) “SVO” means the Securities Valuation Office of the NAIC.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & ORS 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 38-2020, amend filed 08/05/2020, effective 08/07/2020
DMAP 3-2020, temporary amend filed 02/12/2020, effective 02/12/2020 through 08/09/2020
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5005 FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements

(1) A CCO shall assume the risk for providing capitated services under the CCO Contract.

(2) Each CCO must demonstrate that it is able to provide coordinated care services efficiently, effectively, and economically. CCOs shall maintain sound financial management procedures, maintain protections against insolvency, and generate periodic financial reports as provided in these rules.

(3) A CCO shall comply with all applicable laws relating to solvency requirements of CCOs and the terms of the Contract. Solvency requirements shall include the following components:

(a) Maintenance of Restricted Reserve Funds as required by OAR 410-141-5185;

(b) Protection against catastrophic and unexpected loss or expenses related to capitated services for a CCOs Loss Protection Program; A CCO’s Loss Protection Program:

(A) May include stop loss insurance coverage, reinsurance or such other alternative protection(s) as may be approved by the Authority, and

(B) Shall be subject to the Authority’s review and approval.

(c) Any material change to a CCO’s Loss Protection Program shall be submitted to the Authority in writing and shall be subject to the Authority’s review and approval;

(d) Maintenance of professional liability coverage of not less than $1,000,000 per person per incident and not less than $1,000,000 in the aggregate either through binder issued by an insurance carrier or by self-insurance with proof of same acceptable to the Authority; and

(e) Management systems, practices and procedures that capture, compile, and evaluate information and data concerning financial operations. Such systems shall include, without limitation, the following features and functionalities:

(A) Determination of future budget requirements for the next three quarters.

(B) Determination of incurred but not reported expenses.

(D) Tracking claims payment.

(E) Tracking all monies collected from third party resources on behalf of Members.

(F) Documentation of, and reports on the use of, incentive payment mechanisms, risk-sharing, and risk-pooling, as applicable.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5010 FINANCIAL SOLVENCY REGULATION: Procedure for General Financial Reporting and for Determining Financial Solvency Matters

(1) The Authority shall determine financial solvency of a CCO in accordance with OAR 410-141-5005 through OAR 410-141-5469, and the terms of the CCO Contract.

(2) The Authority shall collaborate with DCBS to review CCO financial reports and evaluate financial solvency and may enter into a cooperative agreement with the DCBS to carry out the provisions of OAR 410-141-5005 to OAR 410-141-5469. Only the Authority may take enforcement action or other regulatory sanctions related to OAR 410-141-5005 to OAR 410-141-5380 and the CCO Contract.

(3) When DCBS is working cooperatively with the Authority to carry out the provisions of OAR 410-141-5005 to OAR 410-141-5380:

(a) Any reference to the Authority in these rules shall include DCBS;

(b) Where these rules specify that the Authority may request or receive information or provide a response or take any action, DCBS may act on behalf of the Authority;

(c) CCOs are not required to file financial reports with both the Authority and DCBS except as may otherwise be provided in the CCO Contract;

(d) A response to DCBS shall be considered a response to the Authority, consistent with the objective of providing a single point of reporting by CCOs.

(4) CCO Contract Applicants. Applicants for a CCO Contract shall submit all required information to the Authority as part of the application process, and the Authority shall transmit certain information to DCBS, as necessary, for its review. In making its determination about the qualifications of the applicant, the Authority shall consult with DCBS about the financial materials and reports submitted with the application.

(5) The Authority may address inquiries to or request additional information or clarification from a CCO or its officers in relation to the activities or condition of the CCO or any other matter connected with its transactions.

(a) All such persons shall promptly and truthfully reply to the inquiries using the form of communication required by the Authority and, if the Authority requires, verified by an officer of the CCO;

(b) No person shall file or cause to be filed with the Authority or the Department any report, statement, application, article, or any other information required or permitted to be filed and known to such person to be false or misleading in any material respect.

(6) CCOs may be required to use specific required reporting forms or documents in order to supply information related to financial responsibility, financial solvency, and financial management. The Authority or DCBS, as applicable, shall provide supplemental instructions about the use of these forms.

(7) The standards established in OAR 410-141-5005 through OAR 410-141-5380 are intended align with the regulation of domestic insurers, to the extent the provisions are applicable to CCOs and are in accordance with ORS Chapters 413 and 414. Any reference in these rules to the Insurance Code or to rules or regulations adopted by DCBS under the Insurance Code shall not make a CCO subject to regulation as an insurer, but instead shall be construed to adopt and incorporate such rules by reference as Authority rules applicable to CCOs.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & ORS 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5015 FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting

(1) Financial reports to the Authority. A CCO shall submit the following to the Authority:

(a) On or before April 30 of each year, an unaudited financial statement for the 12-month period ending the 31st day of December immediately preceding;

(b) Unaudited quarterly financial statements each year according to the following schedule:

(A) On or before May 31 for the quarter ending the 31st day of March immediately preceding;

(B) On or before August 31 for the quarter ending the 30th day of June immediately preceding;

(c) On or before June 30 of each year, an audited financial statement for the year ending the 31st of December immediately preceding.

(2) Except as otherwise allowed or required by the Authority, all annual and quarterly financial statements filed by a CCO with the Authority shall:

(a) Follow and be presented in accordance with Statutory Accounting Principles;

(b) Use a form established by the NAIC, including the instructions, and must complete the form according to the instructions:

(A) For the 2024 reporting year, on the annual statement approved for the 2024 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC;

(B) For the 2025 reporting year, on the annual statement approved for the 2025 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC;

(C) For the 2026 reporting year, on the annual statement approved for the 2026 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC;

(D) For the 2027 reporting year, on the annual statement approved for the 2027 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC.

(c) Be verified by the oaths of the president and secretary of the CCO or, in their absence, by two other duly authorized and acting principal officers; and

(d) Include the additional information listed in sections (4), (5) and (6) of this rule.

(3) Audited annual financial statements shall be subject to, and shall comply with, the requirements set forth in OAR 410-141-5020 through OAR 410-141-5040. Additional instructions for the filing of financial statements and reports are posted on the Authority's website at https://www.oregon.gov/oha/hsd/ohp/pages/cco-contract-forms.aspx.

(4) A CCO shall include the following as supplements to the CCO's quarterly and annual financial statement filings, using forms and templates prescribed by the Authority:

(a) An Annual Disclosure of Compensation Exhibit, disclosing the salary and benefits of the three officers or employees having the highest total compensation for the period. This exhibit shall be required only with the CCO's annual Exhibit L filing;

(b) A report of Flexible Services (as defined by OAR 410-141-3500 and 410-141-3845) and additional supplemental information, including care coordination, case management, and Flexible Services expenses. CCOs shall comply with the following additional requirements regarding Flexible Services:

(A) Flexible Services shall be considered in the rate setting consistent with the State 1115 Waiver;

(B) Flexible Services shall be included as Activities that Improve Health Care Quality in the Minimum Medical Loss Ratio Rebate Calculation report.

(d) A report of third-party resources collections (CCO contractor);

(e) A report of Corporate Relationships of Contractors and Incentive Plan Disclosure and Detail (CCOs);

(f) CCO-specific utilization reports;

(g) Any other supplemental information deemed necessary by the Authority and specified in Exhibit L to the CCO Contract.

(5) A CCO shall report the following information in respect of the CCO's Restricted Reserve, using forms and templates prescribed by the Authority:

(a) Identification of custodians, account balances and assets comprising Restricted Reserve Funds held by a third-party;

(b) A bank statement from each custodian of Restricted Reserve Funds of the account balance or aggregate fair market value of the assets comprising the Restricted Reserve Funds held by the custodian;

(d) Documentation of the dollar amount of that liability that is covered by any identified risk-adjustment mechanisms.

(6) A CCO shall report the following information in respect of any Sub-Capitation Arrangements to which the CCO is a party, using forms and templates prescribed by the Authority:

(a) A CCO that sub-capitates any work described in its agreements with the Authority shall require the Sub-Capitated Counterparty to report financial information as specified in the CCO's agreements with the Authority;

(b) CCOs that make sub-capitation payments exceeding an annual amount defined by financial reporting instructions under the CCO Contract shall submit to the Authority on an annual basis the following financial reports with respect to each of the CCO's Sub-Capitated Counterparties:

(A) Statements of revenue, expenses and net income;

(B) Restricted Reserve Account documentation;

(D) Any supplemental information deemed necessary by the Authority.

(7) Following termination of the CCO Contract, the annual reports described in this rule are due for the last calendar year during which the CCO operated, and its quarterly reports are due until its last annual report has been filed.

(8) The CCO shall make such additional filings with the Authority as are required by the CCO's agreement with the Authority and as otherwise may be determined by the Authority from time to time to be necessary under the circumstances.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5020 FINANCIAL SOLVENCY REGULATION: Annual Audited Financial Statements and Auditor’s Report

(1) Annual audited financial statements shall report the financial position of the CCO as of the end of the most recent calendar year and the results of its operations, cash flows and changes in capital and surplus for the year then ended in accordance with the form and content requirements of OAR 410-141-5015.

(2) The audit of the CCO’s annual financial statements shall be performed by an independent accounting firm and shall include, but not limited to:

(a) A report of the independent accounting firm that meets the requirements of this section.

(b) A written statement of opinion by the independent accounting firm based on the firm's audit regarding the CCO's annual financial statements.

(c) A written statement of opinion by an independent actuarial firm with respect to the assumptions and methods used in determining the CCO’s loss reserves, actuarial liabilities and related items, and the consistency of those assumptions and methods with generally accepted actuarial standards and practices for such matters.

(3) Each CCO required to file an annual audited financial report must register with the Authority in writing the name and address of the independent certified public accountant or accounting firm retained to conduct the annual audit. A CCO shall register under this rule on or before the later of sixty (60) days following the date on which the CCO first becomes subject to this section.

(4) In addition to the requirement of OAR 410-141-5035, a CCO shall obtain a letter from the independent certified accountant retained by the CCO stating that is aware of the provisions of these rules that relate to CCO accounting and financial matters; and affirming that the accountant will express the opinion of the accountant on the financial statements in terms of their conformity with the Statutory Accounting Principles, specifying exceptions that the accountant believes appropriate.

(5) If the accountant who was the CCO’s certified public accountant for the immediately preceding filed audited financial report is dismissed or resigns, the CCO shall so notify the Authority not later than the fifth business day after the dismissal or resignation. The CCO shall also do the following:

(a) Notify the Authority in a separate letter, not later than the 10th business day after the date of the notice of dismissal or resignation, whether in the 24 months preceding the dismissal or resignation there were any disagreements with the former accountant on any matter of accounting principles or practices, financial statement disclosure or auditing scope or procedure that, if not resolved to the satisfaction of the former accountant, would have caused the former accountant to make reference to the subject matter of the disagreement in connection with the accountant's opinion. The disagreements required to be reported in response to this subsection include both those resolved to the former accountant's satisfaction and those not resolved to the former accountant's satisfaction and are those disagreements that occur at the decision-making level, between personnel of the CCO responsible for presentation of its financial statements and personnel of the accounting firm responsible for rendering its report.

(b) Request the former accountant furnish a letter addressed to the CCO stating whether the accountant agrees with the statements contained in the CCO's letter and, if not, stating the reasons for which the accountant does not agree.

(c) Furnish the Authority the letter received from the former accountant under subsection (b) of this section together with a response by the CCO to that letter.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5025 FINANCIAL SOLVENCY REGULATION: Qualifications of Independent Certified Public Accountant

(1) The Authority shall not recognize any person as a qualified independent certified public accountant for the purposes of OAR 410-141-5020, or accept an annual audited financial report that is prepared in whole or in party by a person, if the person:

(a) Is not in good standing with the AICPA and in all states in which the person is licensed to practice as a certified public accountant;

(b) Has either directly or indirectly entered into an agreement of indemnity or a release from liability (collectively referred to as indemnification) with respect to the audit of the CCO;

(c) Has been convicted of fraud, bribery, a violation of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. Sections 1961-1968, or any dishonest conduct or practices under federal or state law;

(d) Has been found to have violated the laws of this state with respect to any previous reports submitted under OAR 410-141-5020 or to DCBS; or

(e) Has demonstrated a pattern or practice of failing to detect or disclose material information in any report filed under OAR 410-141-5020 or to DCBS.

(2) Except as otherwise provided in this section, the Authority shall recognize an independent certified public accountant as qualified as long as the certified public accountant conforms to the standards of the certified public accountant profession, as contained in the Code of Professional Ethics of the AICPA and the rules and the Code of Professional Conduct of the Oregon State Board of Accountancy, or a similar code of conduct of the state board regulating the practice of accountancy in the state in which the accountant is licensed to practice.

(3) A qualified independent certified public accountant may enter into an agreement with a CCO to have disputes relating to an audit resolved by mediation or arbitration. In the event of a delinquency proceeding commenced against the CCO, however, the mediation or arbitration provisions shall operate at the option of the statutory successor.

(4) The lead or coordinating audit partner having primary responsibility for the audit may not act in that capacity for more than five consecutive years, beginning with the year 2020. The partner or other person is disqualified from acting in that or a similar capacity for the same CCO or its subsidiaries or affiliates for a period of five consecutive years. A CCO may request a waiver of this section on the basis of unusual circumstances. A CCO must apply for relief at least 30 days before the end of the calendar year. The Authority may consider the following factors in determining whether the relief should be granted:

(a) The number of partners, the expertise of the partners or the number of CCO and insurance clients in the currently registered firm.

(b) The capitated revenue volume of the CCO.

(5) The Authority may request information to determine whether an independent certified public accountant is qualified and, considering the information presented, may determine that the accountant is not qualified for purposes of expressing the accountant’s opinion on the financial statements in the annual audited financial report made pursuant to OAR 410-141-5020 and require the CCO to replace the accountant with another accountant who is qualified with respect to the CCO as provided in this section.

(6) The Authority may not recognize an accountant as a qualified independent certified public accountant or accept an annual audited financial report prepared in whole or in part by the accountant if the accountant provides to a CCO, contemporaneously with the audit, any of the following non-audit services:

(a) Bookkeeping or other services related to the accounting records or financial statements of the CCO.

(b) Financial information systems design and implementation.

(d) Actuarially-oriented advisory services involving the determination of amounts recorded in the financial statements. The accountant may assist a CCO in understanding the methods, assumptions and inputs used in the determination of amounts recorded in the financial statement only if it is reasonable to conclude that the services provided will not be subject to audit procedures during an audit of the CCO's financial statements. An accountant’s actuary may also issue an actuarial opinion or certification on a CCO’s reserves if all of the following conditions have been met:

(A) Neither the accountant nor the accountant’s actuary has performed any management functions or made any management decisions.

(B) The CCO has competent personnel (or engages a third-party actuary) to estimate the reserves for which management takes responsibility.

(C) The accountant’s actuary tests the reasonableness of the reserves after the ’CO's management has determined the amount of the reserves.

(e) Internal audit outsourcing services.

(f) Management functions or human resources.

(g) Broker or dealer, investment adviser or investment banking services.

(h) Legal services or expert services unrelated to the audit.

(7) In general, the principles of independence with respect to services provided by a qualified independent certified public accountant are largely predicated on three basic principles, violations of which would impair the accountant’s independence. The principles are that the accountant cannot function in the role of management, cannot audit the accountant’s own work, and cannot serve in an advocacy role for the CCO.

(8) A qualified independent certified public accountant who performs the audit may engage in other non-audit services, including tax services, that are not described in subsection (6) and that do not conflict with subsection (7), only if the activity is approved in advance by the CCO’s audit committee in accordance with subsection (9).

(9) All auditing services and non-audit services provided to a CCO by a qualified independent certified public accountant of the CCO shall be preapproved by a duly constituted audit committee of the CCO’s Board. The preapproval requirement is waived with respect to non-audit services if all of the following conditions are met:

(a) The aggregate amount of all such non-audit services provided to the CCO constitutes not more than five percent of the total amount of fees paid by the CCO to its qualified independent certified public accountant during the fiscal year in which the non-audit services are provided.

(b) The services were not recognized by the CCO at the time of the engagement to be non-audit services.

(c) The services are promptly brought to the attention of the audit committee and approved prior to the completion of the audit by the audit committee.

(10) The Authority may not recognize an independent certified public accountant as qualified for a particular CCO if a member of the board, president, chief executive officer, controller, chief financial officer, chief accounting officer or any person serving in an equivalent position for that CCO was employed by the independent certified public accountant and participated in the audit of that CCO during the one-year period preceding the date that the most current statutory opinion is due. This section applies only to partners and senior managers involved in the audit. A CCO may apply to the Authority for relief from the requirement of this subsection on the basis of unusual circumstances pursuant to subsection (4).

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5030 FINANCIAL SOLVENCY REGULATION: Notification of Adverse Financial Condition

(1) A CCO required to furnish an annual audited financial report shall require the independent certified public accountant to report in writing to the CCO’s Board, or to the audit committee of the CCO, any determination by the independent certified public accountant that:

(a) The CCO has materially misstated its financial condition as reported to the Authority as of the date of the balance sheet currently under audit;

(b) The CCO does not meet the minimum capital and surplus requirements under these rules; or

(c) The CCO’s risk-based capital, as determined in accordance with OAR 410-141-5195 to 5220 is below the Company Action Level threshold for the CCO.

(2) The CCO shall require the independent certified public accountant to submit the report no later than the fifth business day after the independent certified public accountant makes such a determination under subsection (1). A CCO that has received a report under this section shall both forward a copy of the report to the Authority and provide the independent certified public accountant with evidence that the report was furnished to the Authority no later than the fifth business day after receiving the report. If the independent certified public accountant does not receive such evidence within the required period, the independent certified public accountant shall furnish to the Authority a copy of its report no later than the fifth business day after the end of the period within which the CCO was required to submit the report.

(3) An independent certified public accountant shall not be liable to any person for any statement made in connection with the requirements of subsection (1) if the statement is made in good faith and in compliance with subsection (1).

(4) If the accountant, after the date of the audited financial report filed pursuant to OAR 410-141-5020, becomes aware of facts that might have affected the report, the Authority notes the obligation of the accountant to act as prescribed in Volume 1, Section AU 561 of the Professional Standards of the AICPA.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5035 FINANCIAL SOLVENCY REGULATION: Accountant's Letter of Qualifications

(1) An accountant shall furnish the CCO, in connection with and for inclusion in the filing of the annual audited financial report, a letter stating the following:

(a) That the accountant is independent with respect to the CCO and conforms to the standards of the accounting profession as contained in the Code of Professional Ethics and pronouncements of the AICPA and the Rules of Professional Conduct of the Oregon State Board of Accountancy, or a similar code of conduct of the state board regulating the practice of accountancy in the state in which the accountant is licensed to practice.

(b) The background and experience in general, and the experience in audits of CCOs, of the staff assigned to the engagement and whether each is an independent certified public accountant.

(c) That the accountant understands that the annual audited financial report and the opinion of the accountant thereon must be filed in compliance with OAR 410-141-5020 and that the Authority will rely on the information contained in the report and opinion in the monitoring and regulation of the financial position of CCOs.

(d) That the accountant consents to the requirements of OAR 410-141-5020 and that the accountant agrees to make the workpapers described in OAR 410-141-5040 available for review by the Authority, or the Authority's designee or appointed agent.

(e) A representation that the accountant is currently licensed by an appropriate state licensing authority and is a member in good standing in the American Institute of Certified Public Accountants.

(f) A representation that the accountant is in compliance with OAR 410-141-5025.

(2) This section does not prohibit an independent certified public accountant from using such staff as the accountant determines appropriate when use of the staff is consistent with the standards prescribed by generally accepted auditing standards.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5040 FINANCIAL SOLVENCY REGULATION: Independent Certified Public Accountants Workpapers

(1) For the purpose of this section, workpapers are the records kept by an independent certified public accountant of the procedures followed, the tests performed, the information obtained and the conclusions reached pertinent to the accountant's audit of the financial statements of a CCO. Accordingly, workpapers may include audit planning documentation, work programs, analyses, memoranda, letters of confirmation and representation, abstracts of company documents and schedules or commentaries prepared or obtained by the independent certified public accountant in the course of the accountant’s audit of the financial statements of a CCO and which support the accountant's opinion.

(2) A CCO that is required to file an audited financial report pursuant to OAR 410-141-5020 shall require the accountant to make available for review by the Authority, all workpapers prepared in the conduct of the accountant’s audit and any communications related to the audit between the accountant and the CCO, at the offices of the CCO, at the Authority’s offices or at any other reasonable place designated by the Authority. The CCO shall require that the accountant retain the audit workpapers and communications until the Authority has filed a report on examination covering the period of the audit but no longer than seven years from the date of the audit report.

(3) In the conduct of a periodic review by the Authority’s examiners, the Authority may make and retain photocopies of pertinent audit workpapers. Any such review by the Authority’s examiners is an investigation and all working papers and communications obtained during the course of such an investigation must be given the same confidentiality as other examination workpapers generated by the Authority.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5045 FINANCIAL SOLVENCY REGULATION: Corporate Governance Annual Disclosure Filing

(1) A CCO shall file a corporate governance annual disclosure (CGAD) report with the Authority, as described in this section, no later than June 1 of each calendar year.

(2) A CGAD Report shall contain the following information:

(a) The CGAD Report shall describe the ’CO's corporate governance framework and structure including consideration of the following:

(A) The CCO’s Board and the various committees thereof that are ultimately responsible for overseeing the CCO and the level(s) at which that oversight occurs (e.g. ultimate control level, intermediate holding company, legal entity, etc.). The CGAD Report shall describe and discuss the rationale for the current CCO Board size and structure.

(B) The duties of the CCO Board and each of its significant committees and how they are governed (e.g. bylaws, charters, informal mandates, etc.), as well as how the CCO Board's leadership is structured, including a discussion of the roles of Chief Executive Officer and Chairman of CCO Board, as applicable, within the organization.

(C) The membership, structure and authority of the CCO’s governing body, if the CCO is a coordinated care organization whose governing body as required by ORS 414.572(2)(o) is not the CCO Board.

(b) The CGAD Report shall describe the policies and practices of the most senior governing entity and significant committees thereof, including a discussion of the following factors:

(A) How the qualifications, expertise and experience of each CCO Board member meets the needs of the CCO.

(B) How an appropriate amount of independence is maintained by the CCO Board and its significant committees.

(C) The number of meetings held by the CCO Board and its significant committees over the past year as well as information on director attendance.

(D) How the CCO or its controlling affiliate nominates and elects members to the CCO Board and its committees. The discussion should include, for example:

(i) Whether a nomination committee is in place to identify and select individuals for consideration.

(ii) Whether term limits are placed on directors.

(iii) How the election and re-election processes function.

(iv) Whether a CCO Board diversity policy is in place and if so, how it functions.

(E) The processes in place for the CCO Board to evaluate its performance and the performance of its committees, as well as any recent measures taken to improve performance (including any Board or committee training programs that have been put in place).

(c) The CGAD Report shall describe the CCO Board’s policies and practices for directing senior management, including a description of the following factors:

(A) Any processes or practices (i.e. suitability standards) to determine whether officers and key persons in control functions have the appropriate background, experience and integrity to fulfill their prospective roles, including identification of the specific positions for which suitability standards have been developed and a description of the standards employed.

(B) Any changes in an officer's or key person's suitability as outlined by the CCO’s standards and procedures to monitor and evaluate such changes.

(i) Compliance with laws, rules and regulations.

(ii) Proactive reporting of any illegal or unethical behavior.

(iii) The CCO’s processes for performance evaluation, compensation and corrective action to ensure effective senior management throughout the organization, including a description of the general objectives of significant compensation programs and what the programs are designed to reward. The description shall include sufficient detail to allow the Authority to understand how the organization ensures that compensation programs do not encourage and/or reward excessive risk taking. Elements to be discussed may include, for example:

(I) The Board's role in overseeing management compensation programs and practices.

(II) The various elements of compensation awarded in the CCO’s compensation programs and how the CCO determines and calculates the amount of each element of compensation paid.

(III) How compensation programs are related to both company and individual performance over time.

(IV) Whether compensation programs include risk adjustments and how those adjustments are incorporated into the programs for employees at different levels.

(V) Any claw back provisions built into the programs to recover awards or payments if the performance measures upon which they are based are restated or otherwise adjusted.

(VI) Any other factors relevant in understanding how the CCO monitors its compensation policies to determine whether its risk management objectives are met by incentivizing its employees.

(iv) The CCO’s plans for senior management succession.

(d) The CGAD Report shall describe the processes by which the CCO Board, its committees and senior management ensure an appropriate amount of oversight to the critical risk areas impacting the CCO’s business activities, including a discussion of:

(A) How oversight and management responsibilities are delegated between the CCO Board, its committees and senior management.

(B) How CCO Board is kept informed of the CCO’s strategic plans, the associated risks and steps that senior management is taking to monitor and manage those risks.

(C) How reporting responsibilities are organized for each critical risk area. The description should allow the Authority to understand the frequency at which information on each critical risk area is reported to and reviewed by senior management and the CCO Board. This description may include, for example, the following critical risk areas of the insurer:

(i) Risk management processes.

(ii) Actuarial function.

(iii) Investment decision-making processes.

(iv) Reinsurance decision-making processes.

(v) Business strategy/finance decision-making processes.

(vi) Compliance function.

(vii) Financial reporting/internal auditing.

(viii) Market conduct decision-making processes.

(3) The chief executive officer or corporate secretary of a CCO shall sign the CGAD Report and attest that to the best of the officer’s or secretary's belief and knowledge the CCO has implemented the corporate governance practices identified in the CGAD Report and that the CCO’s Board, or an appropriate committee of the CCO’s Board, has received a copy of the disclosure.

(4) A CCO that submits a CGAD Report under subsection (1) of this section may provide information in the disclosure at any of the following levels:

(a) At the level of the CCO, an intermediate holding company or any controlling affiliate, depending on how the CCO and its controlling affiliates have structured corporate governance.

(b) At the level at which the CCO or any controlling affiliate oversees or coordinates and exercises supervision over the ’CO's earnings, capital, liquidity operations and reputation.

(5) A CCO shall identify the level at which its CGAD Report is presented and explain the basis on which that level was determined to be appropriate. A CCO also shall explain any subsequent changes in the level of reporting.

(6) The CCO shall have discretion regarding the appropriate format for providing the information required by this section and is permitted to customize the CGAD Report to provide the most relevant information necessary to permit the Authority to gain an understanding of the corporate governance structure, policies and practices utilized by the CCO.

(7) Each year following the initial filing of the CGAD Report, the CCO shall file an amended version of the previously filed CGAD Report indicating where changes have been made. If no changes were made in the information or activities reported by the CCO, the filing should so state.

(8) Upon written application of a CCO, the Authority may grant an exemption from compliance with the CGAD Report filing requirement under this section if the Authority finds upon review of the application that compliance would constitute a financial or organizational hardship upon the CCO. An exemption may be granted at any time and from time to time for a specified period or periods. Not later than the 10th day after denial of a CCO’s written request for an exemption under this section, the CCO may request in writing a hearing on its application for an exemption pursuant to the requirements of OAR 410-141-5082.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5050 FINANCIAL SOLVENCY REGULATION: Requirements for Reinsurance

(1) Except with the prior written approval of the Authority, as outlined in the terms of the CCO Contract, a CCO may not reinsure risks written or insured by other CCOs or other insurers.

(2) A CCO may cede and reinsure risks, on an indemnity reinsurance basis, to another CCO authorized to transact such business in this state or with a health insurer authorized to reinsure such risks provided that such other CCO or such other health insurer has been approved or accepted by the Authority to act as a reinsurer of the CCO and the reinsurance qualifies for financial statement credit to the cedent CCO under this section. The Authority shall not approve or accept any such reinsurance by the cedent CCO in an unauthorized CCO or unauthorized health insurer, or which the Authority finds for good cause would otherwise be contrary to the interests of the Members of the cedent CCO.

(3) Credit shall not be allowed, as an asset or as a deduction from liability, to any cedent CCO for reinsurance unless the reinsurance contract provides, in substance, that in the event of the insolvency of the cedent CCO, the reinsurance shall be payable on the basis of reported claims allowed by the court hearing the liquidation proceeding, without diminution because of the insolvency of the cedent CCO. Such payments shall be made directly to the cedent CCO or to its domiciliary liquidator except when the reinsurer, with the consent of the Authority, has assumed the policy obligations of the cedent CCO as direct obligations of the reinsurer and in substitution for the obligations of the cedent CCO.

(4) For the purposes of subsection (3) of this section, the reinsurance agreement may provide that the domiciliary liquidator of the insolvent cedent CCO shall, within a reasonable time after the claim is filed in the liquidation proceeding, give written notice to the reinsurer of the pendency of a claim against the cedent CCO on the risk reinsured. During the pendency of the claim, the reinsurer may investigate the claim and interpose, at its own expense, in the proceeding in which the claim is to be adjudicated any defenses that the reinsurer determines to be available to the cedent CCO or its liquidator. The reinsurer’s expense in doing so may be filed as a claim against the insolvent cedent CCO to the extent of a proportionate share of the benefit that may accrue to the cedent CCO solely as a result of the defense undertaken by the reinsurer. When two or more reinsurers are involved in the same claim and a majority in interest elect to interpose one or more defenses to the claim, the expense shall be apportioned in accordance with the terms of the reinsurance agreement as though the expense had been incurred by the cedent CCO.

(5) The Authority may disallow financial statement credit for reinsurance that would otherwise be allowed if the Authority determines that allowing credit would be contrary to accurate financial reporting or proper financial management or may be hazardous to Members of the CCO or the public generally.

(6) A cedent CCO promptly shall inform the Authority in writing of the cancellation of, or any other material change to, any of its reinsurance agreements or arrangements.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5055 FINANCIAL SOLVENCY REGULATION: Requirements for Obtaining Credit for Reinsurance

(1) The Authority shall not allow financial statement credit for reinsurance to a cedent CCO as either an asset or a reduction from liability on account of reinsurance ceded unless the reinsurance meets the requirements of subsection (2) or (3) of this section.

(2) Credit shall be allowed when the reinsurance is ceded to an authorized assuming CCO or an authorized health insurer that has been approved and accepted by the Authority to act as a reinsurer of the cedent CCO in accordance with OAR 410-141-5050. The Authority shall not allow credit to a cedent CCO if the approval or acceptance of the reinsurer has been revoked by the Authority after notice and opportunity for hearing.

(3) The Authority shall allow a reduction from liability for reinsurance ceded by a CCO to an assuming reinsurer not meeting the requirements of subsection (2) in an amount not exceeding the liabilities carried by the cedent CCO. The reduction shall be in the amount of funds held by or on behalf of the cedent CCO, including funds held in trust for the exclusive benefit of the cedent CCO, under a reinsurance contract with such reinsurer as security for the payment of obligations under the reinsurance contract. The security must be held in the United States subject to withdrawal solely by and under the exclusive control of the cedent CCO insurer or, in the case of a trust, held in a Qualified United States Financial Institution. The security may be in the form of any of the following:

(a) Cash.

(b) Securities listed by the SVO.

(c) Clean, irrevocable, unconditional and "evergreen" letters of credit issued or confirmed by a Qualified United States Financial Institution effective no later than December 31 of the year for which filing is being made, and in the possession of, or in trust for, the cedent CCO on or before the filing date of its annual statement. Letters of credit meeting applicable standards of issuer acceptability as of the dates of their issuance or confirmation shall, notwithstanding the issuing or confirming institution's subsequent failure to meet applicable standards of issuer acceptability, continue to be acceptable as security until their expiration, extension, renewal, modification or amendment, whichever first occurs.

(d) Any other form of security acceptable to the Authority.

(4) An allowed asset or a reduction from liability for reinsurance ceded to an unauthorized reinsurer pursuant to subsection (3) of this section shall be allowed only when the applicable requirements of OAR 410-141-5050 to OAR 410-141-5070 are satisfied.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5060 FINANCIAL SOLVENCY REGULATION: Qualified Trust Agreements

(1) As used in this section:

(a) “Beneficiary” includes any successor by operation of law of the named beneficiary, including without limitation any liquidator, rehabilitator, receiver or conservator.

(b) “Grantor” means the entity that has established a trust for the sole benefit of the beneficiary. When established in conjunction with a reinsurance agreement, the grantor is the unauthorized or unlicensed unaccredited reinsurer.

(A) Reinsured losses and allocated loss expenses paid by the cedent CCO, but not recovered from the reinsurer;

(B) Reserves for reinsured losses reported and outstanding;

(D) Reserves for allocated reinsured loss expenses and unearned capitated revenue.

(2) The following are required conditions applicable to the trust agreement:

(a) The trust agreement shall be entered into between the beneficiary, the grantor and a trustee that must be a Qualified United States Financial Institution.

(b) The trust agreement shall create a trust account into which assets must be deposited.

(d) The trust agreement shall provide that:

(A) The beneficiary shall have the right to withdraw assets from the trust account at any time, without notice to the grantor, subject only to written notice from the beneficiary to the trustee;

(B) No other statement or document is required to be presented in order to withdraw assets, except that the beneficiary may be required to acknowledge receipt of withdrawn assets;

(D) It shall not contain references to any other agreements or documents except as provided for under subsection (l) of this section.

(e) The trust agreement shall be established for the sole benefit of the beneficiary.

(f) The trust agreement shall require the trustee to:

(A) Receive assets and hold all assets in a safe place;

(B) Determine that all assets are in such form that the beneficiary, or the trustee upon direction by the beneficiary, may whenever necessary negotiate any such assets, without consent or signature from the grantor or any other person or entity;

(C) Furnish to the grantor and the beneficiary a statement of all assets in the trust account upon its inception and at intervals no less frequent than the end of each calendar quarter;

(D) Notify the grantor and the beneficiary within ten days of any deposits to or withdrawals from the trust account;

(E) Upon written demand of the beneficiary, immediately take all steps necessary to transfer absolutely and unequivocally all right, title and interest in the assets held in the trust account to the beneficiary and deliver physical custody of the assets to the beneficiary; and

(F) Allow no substitutions or withdrawals of assets from the trust account, except on written instructions from the beneficiary, except that the trustee may, without the consent of, but with notice to the beneficiary, upon call or maturity of any trust asset, withdraw such asset upon condition that the proceeds are paid into the trust account.

(g) The trust agreement shall provide that at least 30 days but not more than 45 days prior to termination of the trust account, written notification of termination shall be delivered by the trustee to the beneficiary.

(h) The trust agreement shall be made subject to and governed by the laws of the state in which the trust is domiciled.

(i) The trust agreement shall prohibit invasion of the trust corpus for the purpose of paying commissions to or reimbursing the expenses of the trustee.

(j) In order for a letter of credit to qualify as an asset of the trust, the trustee must have the right and the obligation pursuant to the deed of trust or some other binding agreement, as duly approved by the Authority, to immediately draw down the full amount of the letter of credit and hold the proceeds in trust for the beneficiaries of the trust if the letter of credit will otherwise expire without being renewed or replaced.

(k) The trust agreement shall provide that the trustee is liable for its negligence, willful misconduct or lack of good faith. The failure of the trustee to draw against the letter of credit in circumstances in which such a draw would be required shall be deemed to be negligence or willful misconduct, or both.

(L) The trust agreement may provide that the cedent CCO shall undertake to use and apply amounts drawn upon the trust account, without diminution because of the insolvency of the cedent CCO or the reinsurer, only for the following purposes:

(A) To pay or reimburse the cedent CCO for the reinsurer’s share under the reinsurance agreement of any losses and allocated loss expenses paid by the cedent CCO, but not recovered from the reinsurer, or for unearned capitated revenue due to the cedent CCO if not otherwise paid by the reinsurer;

(B) To pay the reinsurer any amounts held in the trust account that exceed 102 percent of the actual amount required to fund the reinsurer’s obligations under the reinsurance agreement; and

(C) When the cedent CCO has received notification of termination of the trust account and if the reinsurer's entire obligations under the reinsurance agreement remain unliquidated and undischarged ten days prior to the termination date, to withdraw amounts equal to the obligations and deposit those amounts in a separate account held apart from its general assets, in the name of the cedent CCO in any Qualified United States Financial Institution, in trust for such uses and purposes specified in paragraphs (A) and (B) of this subsection as may remain executory after such withdrawal and for any period after the termination date.

(3) The following are permitted conditions applicable to the trust agreement:

(a) The trust agreement may provide that the trustee may resign upon delivery of a written notice of resignation, effective not less than 90 days after the beneficiary and grantor receive the notice, and that the trustee may be removed by the grantor by delivery to the trustee and the beneficiary of a written notice of removal, effective not less than 90 days after the trustee and the beneficiary receive the notice, except that such a resignation or removal shall not be effective until a successor trustee has been duly appointed and approved by the beneficiary and the grantor and all assets in the trust have been duly transferred to the new trustee.

(b) The grantor may have the full and unqualified right to vote any shares of stock in the trust account and to receive from time-to-time payments of any dividends or interest upon any shares of stock or obligations included in the trust account. Any such interest or dividends shall be either forwarded promptly upon receipt to the grantor or deposited in a separate account established in the grantor's name.

(c) The trustee may be given authority to invest and accept substitutions of any funds in the account, except that an investment or substitution shall not be made without prior approval of the beneficiary, unless the trust agreement specifies categories of investments acceptable to the beneficiary and authorizes the trustee to invest funds and to accept substitutions that the trustee determines are at least equal in market value to the assets withdrawn.

(d) The trust agreement may provide that the beneficiary may at any time designate a party to which all or part of the trust assets are to be transferred. Such a transfer may be conditioned upon the trustee receiving other specified assets prior to or simultaneously with the transfer.

(e) The trust agreement may provide that, upon termination of the trust account, all assets not previously withdrawn by the beneficiary shall be delivered to the grantor with written approval by the beneficiary.

(4) The following are additional conditions applicable to reinsurance agreements:

(a) A reinsurance agreement may contain provisions that:

(A) Require the reinsurer to enter into a trust agreement and to establish a trust account for the benefit of the cedent CCO and specify what the agreement is to cover.

(B) Stipulate that assets deposited in the trust account shall be valued according to their current fair market value and shall consist only of cash in United States dollars; certificates of deposit issued by a United States bank and payable in United States dollars; and investments permitted by OAR 410-141-5095 to 410-141-5165 or any combination thereof, except that investments in or issued by an entity controlling, controlled by or under common control with either the grantor or the beneficiary of the trust shall not exceed five percent of total investments.

(C) Require the reinsurer, prior to depositing assets with the trustee, to execute assignments or endorsements in blank, or to transfer legal title to the trustee of all shares, obligations or any other assets requiring assignments, in order that the cedent CCO, or the trustee upon the direction of the cedent CCO, may whenever necessary negotiate these assets without consent or signature from the reinsurer or any other entity.

(D) Require that all settlements of account between the cedent CCO and the reinsurer be made in cash or its equivalent.

(E) Stipulate that the reinsurer and the cedent CCO agree that the assets in the trust account, established pursuant to the provisions of the reinsurance agreement, may be withdrawn by the cedent CCO at any time, notwithstanding any other provisions in the reinsurance agreement, and shall be used and applied by the cedent CCO or its successors in interest by operation of law, including without limitation any liquidator, rehabilitator, receiver or conservator of the cedent CCO, without diminution because of insolvency on the part of the cedent CCO or the reinsurer, only for the following purposes:

(i) To pay or reimburse the cedent CCO for:

(I) The reinsurer's share under the specific reinsurance agreement of unearned capitated revenue returned, but not yet recovered from the reinsurer.

(II) The reinsurer's share of benefits or losses paid by the cedent CCO pursuant to the provisions of the CCO Contract reinsured under the reinsurance agreement.

(III) Any other amounts necessary to secure the credit or reduction from liability for reinsurance taken by the cedent CCO.

(ii) To make payment to the reinsurer of amounts held in the trust account in excess of the amount necessary to secure the credit or reduction from liability for reinsurance taken by the cedent CCO.

(b) The reinsurance agreement may also contain provisions that:

(A) Give the reinsurer the right to seek the cedent CCO's approval, which the cedent CCO shall not unnecessarily or arbitrarily withhold, to withdraw from the trust account all or any part of the trust assets and transfer those assets to the reinsurer. The right to seek approval under this paragraph must be subject to one of the following requirements:

(i) The reinsurer shall, at the time of withdrawal, replace the withdrawn assets with other qualified assets having a market value equal to the market value of the assets withdrawn so as to maintain at all times the deposit in the required amount; or

(ii) After withdrawal and transfer, the market value of the trust account is no less than 102 percent of the required amount.

(B) Provide for:

(i) The reinsurer’s return of any amount withdrawn in excess of the actual amounts required under subsection (2)(l)(B) of this section; and

(ii) Interest payments at a rate not in excess of the prime rate of interest on the amounts held in trust pursuant to this section.

(iii) Permit the award by any arbitration panel or court of competent jurisdiction of:

(I) Court or arbitration costs;

(II) Attorney fees; and

(III) Any other reasonable expenses.

(c) A trust agreement may be used to reduce any liability for reinsurance ceded to an unauthorized reinsurer in financial statements required to be filed with the Authority in compliance with the provisions of OAR 410-141-5010 to 5020 when established on or before the date of filing of the financial statement of the cedent CCO. The reduction for the existence of an acceptable trust account may be up to the current fair market value of acceptable assets available to be withdrawn from the trust account at that time, but such reduction shall be no greater than the specific obligations under the reinsurance agreement that the trust account was established to secure.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5065 FINANCIAL SOLVENCY REGULATION: Letters of Credit; Other Security

(1) A letter of credit for purposes of OAR 410-141-5055 must be clean, irrevocable, unconditional and issued or confirmed by a Qualified United States Financial Institution. The letter of credit shall contain an issue date and date of expiration and shall stipulate that the beneficiary need only draw a sight draft under the letter of credit and present it to obtain funds and that no other document need be presented.

(2) The letter of credit shall also indicate that it is not subject to any condition or qualifications outside of the letter of credit. In addition, the letter of credit itself shall not contain reference to any other agreements, documents or entities.

(3) As used in this section, “beneficiary” means the CCO for whose benefit the letter of credit has been established and any successor of the beneficiary by operation of law. If a court of law appoints a successor in interest to the named beneficiary, then the named beneficiary includes and is limited to the court-appointed domiciliary receiver (including conservator, rehabilitator or liquidator).

(4) The heading of the letter of credit may include a boxed section containing the name of the applicant and other appropriate notations to provide a reference for the letter of credit. The boxed section shall be clearly marked to indicate that such information is for internal identification purposes only.

(5) The letter of credit shall contain a statement to the effect that the obligation of the Qualified United States Financial Institution under the letter of credit is in no way contingent upon reimbursement with respect thereto.

(6) The term of the letter of credit shall be for at least one year and shall contain an “evergreen clause” that prevents the expiration of the letter of credit without due notice from the issuer. The “evergreen clause” shall provide for a period of not less than 30 days' notice prior to expiration date or nonrenewal.

(7) The letter of credit shall state whether it is subject to and governed by the laws of this state or the Uniform Customs and Practice for Documentary Credits of the International Chamber of Commerce (Publication 600), or International Standby Practices of the International Chamber of Commerce Publication 590 (ISP98), or any successor publication, and all drafts drawn thereunder shall be presentable at an office in the United States of a Qualified United States Financial Institution.

(8) If the letter of credit is made subject to the Uniform Customs and Practice for Documentary Credits of the International Chamber of Commerce (Publication 600), or any successor publication, the letter of credit shall specifically address and provide for an extension of time to draw against the letter of credit in the event that one or more of the occurrences specified in Article 17 of Publication 600, or any successor publication, occur.

(9) The letter of credit shall be issued or confirmed by a Qualified United States Financial Institution authorized to issue letters of credit.

(10) The following apply to reinsurance agreement provisions:

(a) The reinsurance agreement in conjunction with which the letter of credit is obtained may contain provisions described in this subsection. All of the provisions of this subsection must be applied without diminution because of insolvency on the part of the cedent CCO or reinsurer. The provisions are as follows:

(A) A provision requiring the reinsurer to provide letters of credit to the cedent CCO and specify what they are to cover.

(B) A provision stipulating that the reinsurer and cedent CCO agree that the letter of credit provided by the reinsurer pursuant to the provisions of the reinsurance agreement may be drawn upon at any time, notwithstanding any other provisions in the agreement, and must be used by the cedent CCO or its successors in interest only for one or more of the following reasons:

(i) To pay or reimburse the cedent CCO for:

(I) The reinsurer's share under the specific reinsurance agreement of unearned capitated revenue returned, but not yet recovered from the reinsurers;

(II) The reinsurer's share, under the specific reinsurance agreement, of benefits or losses paid by the cedent CCO, but not yet recovered from the reinsurers, under the terms and provisions of the CCO Contracts reinsured under the reinsurance agreement; and

(III) Any other amounts necessary to secure the credit or reduction from liability for reinsurance taken by the cedent CCO.

(ii) When the letter of credit will expire without renewal or be reduced or replaced by a letter of credit for a reduced amount and when the reinsurer's entire obligations under the specific reinsurance remain unliquidated and undischarged ten days prior to the termination date, to withdraw amounts equal to the reinsurer's share of the liabilities, to the extent that the liabilities have not yet been funded by the reinsurer and exceed the amount of any reduced or replacement letter of credit, and deposit those amount in a separate account in the name of the cedent CCO in a Qualified United States Financial Institution apart from its general assets, in trust for such uses and purposes specified in subparagraph (i) of this paragraph as may remain after withdrawal and for any period after the termination date.

(b) Nothing contained in subsection (10)(a) shall preclude the cedent CCO and reinsurer from providing for:

(A) An interest payment, at a rate not in excess of the prime rate of interest, on the amounts held pursuant to subsection (10)(a)(B); or

(B) The return of any amounts drawn down on the letters of credit in excess of the actual amounts required for the above or any amounts that are subsequently determined not to be due.

(11) A cedent CCO may take credit for unencumbered funds withheld by the cedent CCO in the United States subject to withdrawal solely by the cedent CCO and under its exclusive control.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5070 FINANCIAL SOLVENCY REGULATION: Assets, Liabilities, Reserves

(1) In any determination of the financial condition of a CCO, only assets owned by the CCO are allowed which consist of the following:

(a) Cash in the possession or control of the CCO, including the true balance of any deposit in a solvent bank or trust company.

(b) Investments permitted by OAR 410-141-5095 to 410-141-5165 and held in accordance with these rules, and due or accrued income items in connection therewith to the extent considered by the Authority to be collectible.

(d) Amounts recoverable from reinsurers if credit for reinsurance may be allowed to the CCO pursuant to OAR 410-141-5050 to 410-141-5070.

(e) Other assets considered by the Authority to be available for the payment of losses and claims, at values determined by the Authority.

(2) In addition to assets specifically excluded by subsection (1), the following shall not be allowed as assets in any determination of the financial condition of a CCO:

(a) Advances to officers, employees, agents and other persons on personal security only.

(b) Stock or other equivalent equity interests of such CCO owned by it, or any material equity therein or loans secured thereby, or any material proportionate interest in such stock or equivalent equity interest acquired or held through the ownership by such CCO of an interest in another firm, corporation or business unit.

(c) Tangible personal property, except such property as the CCO is otherwise permitted to acquire and retain as an investment under these rules and which is deemed by the Authority to be available for the payment of losses and claims or which is otherwise expressly allowable, in whole or in part, as an asset.

(d) The amount, if any, by which the book value of any investment as carried in the ledger assets of the CCO exceeds the value thereof as determined under these rules.

(3) In any determination of the financial condition of a CCO, liabilities to be charged against its assets shall be calculated in accordance with these rules and shall include:

(a) The amount necessary to pay all of its unpaid losses and claims incurred on or prior to the date of the statement, whether reported or unreported to the CCO, together with the expenses of adjustment or settlement thereof.

(b) A reserve equal to the unearned portion of capitated revenue held by the CCO as of the financial statement date.

(c) Reserves which place a sound value on its liabilities and which are not less than the reserves according to accepted actuarial standards consistently applied and based on actuarial assumptions relevant to CCO Contract provisions.

(d) Taxes, expenses and other obligations due or accrued at the date of the statement.

(e) Any additional reserves for asset valuation contingencies or loss contingencies required by these rules or considered to be necessary by the Authority for the protection of the Authority and the Members of the CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5075 FINANCIAL SOLVENCY REGULATION: Disallowance of Certain Reinsurance Transactions

(1) The Authority shall disallow as an asset or as a credit against liabilities any reinsurance found by the Authority to have been arranged for the purpose principally of deception as to the ceding CCO’s financial condition as of the date of any financial statement of the CCO. A CCO shall follow the process for approval outlined in the CCO Contract.

(2) Without limiting the significance of the subsection (1), reinsurance of any substantial part of the CCO’s outstanding risks placed within four months prior to the date of any such financial statement and canceled in fact within eight months after the date of such statement, or reinsurance under which the reinsurer bears no substantial insurance risk or substantial risk of net loss to itself, shall be deemed to have been arranged for the principal purpose of deception.

(3) The Authority shall disallow as an asset any deposit, funds or other assets of the CCO found by the Authority:

(a) Not to be the property of the CCO;

(b) Not freely subject to withdrawal or liquidation by the CCO at any time for the payment or discharge of claims or other obligations arising under its CCO Contracts; or

(c) To result from arrangements made principally for the purpose of deception as to the CCO’s financial condition as of the date of any financial statement of the CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5080 FINANCIAL SOLVENCY REGULATION: Transparency

(1) Pursuant to ORS 414.018 and 414.593(2), interactions between the Authority and CCOs shall be done in a transparent and public manner.

(2) The Authority shall publicly disclose all information pertaining to CCOs required by ORS 414.593(3) that is not deemed confidential in this subsection. Such confidential documents include:

(a) Certain documents pertaining to a CCO’s financial condition, as described in these rules.

(b) Financial analysis solvency tools and analytical reports developed by the NAIC, and comparable reports developed or used by DCBS or the Authority.

(c) Any work papers, recorded information, documents and copies thereof that are produced or obtained by or disclosed to the Authority or DCBS, or any other person in the course of an examination or in the course of analysis by the Authority or DCBS of the financial condition or market conduct of an CCO, if the CCO specifically designates the confidential portions and cites an exemption from public disclosure under the Oregon Public Records Law, ORS 192.311 to 192.478. The Authority may, in its sole discretion, determine that the exemption cited by the CCO does not apply or disclosure is necessary to protect the public interest, in accordance with Oregon Public Records Law.

(3) The Authority may use a confidential document, material or other information in administering these rules and in any regulatory or legal action brought as a part of the Authority’s duties. In order to assist in the performance of the Authority’s duties, the Authority may:

(a) Authorize sharing a confidential document, material or other information as appropriate among the administrative divisions and staff offices of the Authority or DCBS for the purpose of administering and enforcing the statutes within the authority of the Authority, in order to enable the administrative divisions and staff offices to carry out their functions and responsibilities;

(b) Share a document, material or other information, including a confidential document, material or other information that is subject to this rule or that is otherwise exempt from disclosure under ORS 192.311 to 192.478, in response to a request from the NAIC or a state, federal, foreign, or international law enforcement agency.

(4) Upon notice or with an understanding that the document, material or other information is confidential or privileged under the laws of the jurisdiction that is the source of the document, material or other information, the Authority shall maintain the confidentiality of documents, materials or other information received from state, federal, foreign and international regulatory and law enforcement agencies and from the NAIC.

(5) The Authority’s use, sharing, and disclosure of a document, material or other information does not waive an applicable privilege or claim of confidentiality in the document, material or other information.

(6) The Authority may release a final, adjudicated action, including the termination of a CCO Contract, if the action is otherwise open to public inspection, to a database or other clearinghouse service maintained by the NAIC or affiliates or subsidiaries of the NAIC.

(7) All information, documents and copies thereof obtained by or disclosed to the Authority, DCBS or any other person in the course of an examination or investigation made or conducted under these rules shall be subject to the provisions of OAR 410-141-5305.

(8) ORS 414.593 requires the Authority to make readily available to the public on an easily accessible website, and to annually report to the Legislative Assembly, certain information regarding each CCO contracting with the Authority. Nothing in this rule shall be construed as making confidential any information described in the previous sentence.

(9) Nothing in this rule shall be construed as waiving the Confidentiality requirements of OAR 410-141-5278.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5085 ASSET VALUATION AND PERMITTED INVESTMENTS: Definitions

As used in OAR 410-141-5085 to 410-141-5165:

(1) “Amply secured obligation” means an obligation which is not in default and as to which no default is imminent, and which satisfies the requirements of one or more of the following subsections:

(a) An obligation of a sovereign or political subdivision thereof, if it is issued, assumed or guaranteed by the governmental unit involved and is payable either from:

(b) Taxes levied or which may be levied by such governmental unit; or

(c) Adequate special revenues pledged or otherwise appropriated or required by law to be used for the purpose of such payment, provided the law authorizing the issuance of the obligation requires that adequate rates be fixed, maintained and collected at all times so as to produce sufficient revenue or earnings to pay all operating expenses, maintenance charges, and the principal, interest and dividends on the obligation. An obligation payable solely out of special assessments on real property benefited by local improvements shall not be considered amply secured unless the total amount so payable is less than 50 percent of the market value of the real property (including any improvements thereon) and constitutes a lien on such property.

(d) An obligation issued, assumed or guaranteed by a corporation, if the corporation is solvent, has not been in default on any of its obligations during the preceding three years, and if the obligation is secured by the pledge of property the market value of which exceeds the amount of the obligation by 25 percent or more. Obligations which are the subject of OAR 410-141-5105 and OAR 410-141-5110 are not included within the provisions of this subsection.

(e) An obligation otherwise found to be amply secured by the Authority. In making such determinations, the Authority shall give consideration to model laws, model regulations and other statutory accounting guidance pertaining to amply secured obligations issued from time to time by the NAIC, and shall consider the financial condition of the issuing, assuming or guaranteeing corporation as well as the existence or absence of any pledge of property as security.

(2) “Corporation” means a corporation, joint stock association or business trust organized and existing under the laws of a sovereign.

(3) “Improved real property” means:

(a) Farmland used for tillage, crop or pasture;

(b) Real estate on which permanent improvements, or improvements under construction or in process of construction, suitable for residence, institutional, commercial or industrial use, are situated; and

(c) Real estate to be developed for the use or uses set forth in subsection (2) of this section on which improvements, or improvements under construction or in process of construction, such as streets, sidewalks, sewers and utilities which will become an integral part of such development, are situated.

(4) “Obligation” means a bond, debenture, note, warrant, certificate or other evidence of indebtedness.

(5) “Political subdivision” means an incorporated county, city, town, village, municipality, or subdivision thereof, or a public corporation, district, agency, commission, authority or instrumentality, or subdivision thereof.

(6) “Sovereign” means the United States, or a state, or Canada or a province thereof.

(7) “Unencumbered” means the nonexistence of any lien, burden or charge having priority over the lien securing the CCO's investment. The following shall not be considered encumbrances on real property or leasehold interests therein:

(a) Reservations of mineral, oil or timber rights, easements, rights of way, sewer rights or rights of walls.

(b) Liens for taxes or assessments not delinquent.

(d) Where the loan is secured by a lien upon real property, a lease under which rents or profits are reserved to the owner, if in any event the security for the loan would be a first lien upon the real property except for such lease.

(e) Where the loan is secured by a lien on a leasehold, a prior lien on the real property, provided the security for the loan is a first lien upon the leasehold and there exists no provision preventing the CCO from continuing the lease in force for the duration of the lease or no condition or rights of reentry or forfeiture under which such lien can be cut off, subordinated or otherwise disturbed so long as the lessee's obligations under the lease are discharged.

History

Statutory/Other Authority: ORS 413.042, 414.615, 414.625 & 414.635
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5090 ASSET VALUATION AND PERMITTED INVESTMENTS: Calculation of Value; Books and Records

(1) Securities held by a CCO, other than bonds or other evidences of debt to which OAR 410-141-5095, applies, must be valued in the discretion of the Authority at their market value, at their appraised value or at prices determined by the Authority as representing their fair market value.

(2) Preferred or guaranteed stocks or shares while paying full dividends may be carried at a fixed value instead of market value, at the discretion of the Authority and in accordance with any method of valuation approved by the Authority.

(3) Stock of a subsidiary corporation of a CCO may not be valued at an amount in excess of the net value thereof as based upon the assets only of the subsidiary that would be eligible under OAR 410-141-5095 to 410-141-5140 for investment of the funds of the CCO directly.

(4) The Authority may determine the method of calculating values as provided in this section, but the method or valuation may not be inconsistent with any applicable method or valuation used by CCOs in general or any such method of valuation then currently formulated or approved by the NAIC or its successor organization.

(5) Assets may be allowed as deductions from corresponding liabilities, liabilities may be charged as deductions from assets, deductions from assets may be charged as liabilities, and deductions from liabilities may be allowed as assets, in accordance with the form of annual statement prescribed by the Authority, or otherwise in the discretion of the Authority.

(6) A CCO shall keep its books, records, accounts and transaction source data in such manner that the Authority may readily verify its statements of financial condition and ascertain whether the CCO is unimpaired, has given proper treatment to Members and has complied with state and federal law.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5095 ASSET VALUATION AND PERMITTED INVESTMENTS: Assets Other Than Securities; Bonds; Real Property; Mortgages; Compensating Balances

(1) Each bond or other evidence of debt having a fixed term and rate of interest may be valued as follows, if amply secured and not in default as to principal or interest:

(a) If purchased at par, at the par value.

(b) If purchased above or below par, according to an accepted method of valuation approved by the Authority.

(2) For the purpose of subsection (1) of this section, the purchase price shall not be a higher amount than the actual market value at the time of purchase, plus actual brokerage, transfer, postage or express charges paid in the acquisition of such bond or other evidence of debt.

(3) For purposes of subsections (1) and (2) of this section, the Authority may determine the method of calculating values. The method or valuation may not be inconsistent with any applicable method or valuation used by CCOs in general or any such method or valuation then currently formulated or approved by the NAIC or its successor organization.

(4) Real property shall be valued as follows:

(a) Real property acquired pursuant to a mortgage loan or contract of sale shall be valued at an amount not greater than the unpaid principal of the defaulted loan or contract at the date of such acquisition, together with any taxes and expenses paid or incurred in connection with such acquisition, and the cost of improvements thereafter made by the CCO and any amounts thereafter paid by the CCO on assessments levied for improvements in connection with the property.

(b) Other real property held by a CCO shall be valued at an amount not in excess of the cost of the acquired property and the cost of improvements thereafter made by the CCO, less a reasonable allowance for depreciation.

(5) Purchase money mortgages on real property referred to in subsection (4)(a) of this section shall be valued in an amount not exceeding the acquisition cost of the real property covered thereby or 90 percent of the fair value of such real property, whichever is less.

(6) Other assets, other than securities, shall be valued at cost of acquisition less any repaid portion thereof, unless the Authority determines that another value is proper.

(7) Except as provided in OAR 410-141-5100, funds of a CCO shall not be used as compensating balances for loans to other persons, or otherwise pledged for the benefit of other persons.

(8) A CCO shall not have any combination of investments in or secured by the stocks, obligations, and property of one person, corporation or political subdivision in excess of 10 percent of the CCO’s assets, nor shall it invest more than 10 percent of its assets in a single parcel of real property or in any other single investment. This subsection does not apply to:

(a) Investments in, or loans upon, the security of the general obligations of a sovereign.

(b) Investments by a CCO in all real or personal property used exclusively by such CCO to provide health services or in real property used primarily for its home office.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5100 ASSET VALUATION AND PERMITTED INVESTMENTS: Investments Used to Provide Compensating Balances

Investments of a CCO of the kind described in OAR 410-141-5105(2) that are made for the purpose of providing compensating balances for other persons will not be prohibited by OAR 410-141-5140 while the following conditions are met:

(1) The investment is made in the name of and remains the sole property of the CCO;

(2) The investment is not subject to appropriation in any manner by any person, including the person for whom the compensating balance is being provided, the institution in which the deposit is made and other creditors of such persons;

(3) The CCO holds an irrevocable written waiver from the depositary institution, in a form satisfactory to the Authority, waiving all right, title and interest in or to any setoff, banker's or similar lien or other security interest in such investment or any funds represented thereby;

(4) The investment is unrestricted as to right of withdrawal except for such restrictions as may be usual and customary for such investments under OAR 410-141-5105(2) when no compensating balance is involved; and

(5) The CCO receives a reasonable fee, taking into consideration its return on other funds, for providing the compensating balance involved.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5105 ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Required Capitalization

(1) Funds of a CCO at least equal to its required capitalization shall be invested and kept invested as follows:

(a) In amply secured obligations of the United States, a state or a political subdivision of this state.

(b) In loans secured by first liens upon improved, unencumbered real property (other than leaseholds) in this state where:

(A) The lien does not exceed 50 percent of the appraised value of the property and the loan is for a term of five years or less;

(B) The lien does not exceed 66-2/3 percent of the appraised value of the property provided there is an amortization plan mortgage, deed of trust or other instrument under the terms of which the installment payments are sufficient to repay the loan within a period of not more than 25 years; or

(C) The investment is insured or guaranteed by the Federal Housing Administration, the United States Department of Veterans Affairs, or under Title I of the Housing Act of 1949 (providing for slum clearance and redevelopment projects) enacted by Congress on July 15, 1949.

(2) In deposits, certificates of deposit, deposit accounts, savings accounts, or certificate shares or accounts of or in banks, trust companies, savings and loan associations or building and loan associations to the extent such investments are insured by the Federal Deposit Insurance Corporation.

(3) Investments made pursuant to this section shall be kept free of any lien or pledge. The term “lien or pledge” as used in this section shall not include a deposit of securities with a sovereign, nor assets held in trust for the benefit or protection of all or any class of policyholders of a CCO.

(4) Funds of a CCO may be invested in amply secured obligations of a sovereign, political subdivision thereof or corporation. Expressly included, but not by way of limitation, are obligations of the following federal agencies and authorities: Federal Home Loan Banks, Federal Land Banks, Home Owners Loan Corporation, Public Housing Authorities (to the extent that such obligations are secured by a pledge of annual contributions to be paid by the United States or an agency thereof), and Federal Intermediate Credit Banks.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5110 ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Mortgage Loans

(1) Funds of a CCO may be invested in:

(a) Loans secured by first liens upon improved, unencumbered real property (other than leaseholds) in the manner and subject to the same terms and conditions set forth in OAR 410-141-5105, except that the property may be located within the boundaries of any sovereign; for loans described in OAR 410-141-5105 (1)(b)(B), the maximum permitted ratio of the loan to the appraised value shall be 80 rather than 66-2/3 percent, and the maximum term of the loan shall be 30 rather than 25 years.

(b) Loans secured by first liens upon a leasehold of improved, unencumbered real property located within the boundaries of any sovereign if:

(A) The leasehold has a period of not less than 20 years to run from the date of the loan, inclusive of the term which may be provided by an enforceable option of renewal, the loan does not exceed 70 percent of the fair market value of the leasehold together with any improvements located thereon which are subject to the lien, the terms of the loan provide for amortization payments to be made by the borrower on the principal thereof at least once in each year in amounts sufficient to completely amortize the loan within a period of four-fifths of the term of the leasehold, and the CCO is entitled to be subrogated to all rights of the lessee under the leasehold; or

(B) The investment is insured or guaranteed in the manner provided in OAR 410-141-5105 (1)(b)(C).

(2) A loan upon the security of real property or a leasehold interest therein which is a participation in or a part of a series or issue shall not be made unless the CCO holds a senior participation or similar security interest in the mortgage or deed of trust giving it substantially the rights of a first mortgagee.

(3) Nothing in OAR 410-141-5085 to 410-141-5165 shall prohibit a CCO from renewing or extending a proper loan secured by a first lien upon real property or a leasehold interest therein made pursuant to this section or to OAR 410-141-5105 for the original or a lesser amount even though such amount is a greater percentage of the current fair market value of the real property or leasehold than would otherwise be permitted under such sections.

(4) On loans secured by liens upon real property or leasehold interests therein, the buildings and other improvements located on the premises shall be kept insured against loss or damage from fire in an amount not less than the unpaid balance of the obligation or the insurable value of the property, whichever is the lesser. The fire insurance policy or policies shall be payable to the CCO, or a trustee for its benefit, and continued in force until the loan is repaid or satisfied. Such policy or policies shall be held by the CCO or the trustee, unless the Authority has determined that a different method of protecting the CCOs against loss is satisfactory and has given prior approval of such method to the CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5115 ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Real Property

(1) Except as otherwise provided in OAR 410-141-5105 and OAR 410-141-5110, a CCO may invest in real property only if used for the purposes or acquired in the manner and within the limits as follows:

(a) A CCO may invest in the land and the buildings thereon in which it has its principal office, and in such other real property as required for its convenient accommodation in the transaction of business. Such investments shall not exceed in the aggregate ten percent of the assets of the CCO, except with the consent of the Authority.

(b) A CCO may invest in real property that is acquired in satisfaction of loans, mortgages, liens, judgments or debts previously owing to the CCO in the course of its business.

(c) A CCO may invest in real property acquired in part payment of the consideration on the sale of other real property owned by the CCO if the transaction does not increase the investment of the CCO in real property.

(d) A CCO may invest in real property acquired by gift or devise or through merger, consolidation or bulk reinsurance of another CCO.

(e) A CCO may invest in the vendor's interest in real property subject to a contract of sale. The amount invested in the vendor's interest under such a contract shall not exceed, except with the consent of the Authority:

(A) Ninety percent of the market value of the subject real property, when the real property is one, or two-family residential property.

(B) Eighty percent of the market value of the subject real property, when the real property is other than that described in subparagraph (A) of this paragraph.

(f) A CCO may invest in real property or any interest therein that is acquired or held by purchase, lease or otherwise, other than real property used primarily for agricultural, ranch, mining, development of oil or mineral resources, recreational, amusement or club purposes, if the real property or interest therein is acquired as an investment for the production of income or acquired to be improved or developed for such investment purposes pursuant to an existing program therefor. A CCO may hold, improve, develop, maintain, manage, lease, sell and convey real property acquired by it under this paragraph. Real property and interests therein so acquired may be leased or sublet. Except with the consent of the Authority, a CCO shall not have an amount exceeding five percent of its assets at any one time invested in real property and interests therein under this paragraph.

(g) A CCO may invest in additional real property and in equipment incident to real property if necessary or convenient for the purpose of enhancing the sale or other value of real property previously acquired or held by the CCO under paragraph (b), (c), (d) or (f) of this subsection. The real property and equipment shall be included, together with the real property for the enhancement of which it was acquired, for the purpose of applicable investment limits.

(h) A CCO may invest in real property without regard to whether the property is income-producing when acquired if the CCO intends to improve the property for resale or if the CCO intends that the property shall be income-producing. The CCO may also invest in real property that is income-producing and used primarily for agricultural, ranch, mining, development of oil or mineral resources, recreational, amusement or club purposes. Funds invested under this paragraph shall not exceed the lesser of five percent of the CCO's assets or fifty percent of the CCO's capital and surplus, except with the consent of the Authority.

(i) Except with the consent of the Authority, all real property owned by the CCO under this subsection, except as to properties described in paragraphs (a) and (e) of this subsection, shall not at any time exceed 10 percent of the assets of the CCO.

(2) Except as otherwise provided in subsection (3) of this section:

(a) Real property acquired under this section shall be disposed of within five years after it ceases to be income-producing or to be used by the CCO for its business operation, whichever is later.

(b) Real property acquired under subsection (1)(h) of this section that is not income-producing when acquired shall be disposed of within five years after acquisition if the real property is not improved for resale or if the real property is not income-producing during the five years.

(c) When an investment or any combination of investments by a CCO in real property exceeds any applicable limitation under this section other than a limitation of time, the CCO, not later than the fifth year after the limitation is exceeded, shall dispose of sufficient real property that is subject to the limitation to comply with the limitation.

(3) Any real property acquired under this section that otherwise qualifies as an investment under OAR 410-141-5085 to 410-141-5165 may be retained and held if approved as an investment in the manner prescribed by OAR 410-141-5155 and 410-141-5160. The Authority may extend the time limit prescribed in subsection (2) of this section if the interests of the CCO shall suffer by a “forced sale” of the property.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5120 ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Corporate Stocks

(1) Funds of a CCO may be invested in stocks (including trust certificates) of solvent corporations organized and carrying on a business under the laws of a sovereign as follows:

(a) Preferred or guaranteed stocks if the corporation is not in default or arrears as to any preferred or guaranteed dividend and has continuously and regularly paid such dividends during the preceding three years or has paid cash dividends for five years on common stock.

(b) Common stocks as provided in paragraph (c) of this subsection if:

(A) The obligations and preferred stock, if any, of such corporation are eligible for investment under these rules; and

(B) The stock is registered on a national securities exchange regulated under the Securities Exchange Act of 1934, 15 U.S.C. §§ 78a et seq., or if of a type not commonly so registered is regularly traded on a broad national or regional basis.

(C) Notwithstanding OAR 410-141-5165(1), not more than twenty five percent of admitted assets may be in common stocks that have not paid a cash dividend during each of the five years preceding the date of acquisition.

(2) A CCO shall not invest so as to own or control more than five percent of the voting power outstanding of a corporation, nor shall it invest in the obligations or stocks of a corporation if the CCO and its directors, trustees and officers own or control, or as a result thereof shall own and control, in the aggregate more than 50 percent of the voting power. This subsection does not apply to limit the amount of a CCO’s assets that may be invested in the voting securities of a depository institution or any company that controls the depository institution.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5125 ASSET VALUATION AND PERMITTED INVESTMENTS: Loans; Security; Limitations

(1) Funds of a CCO may be invested in loans secured by pledges of obligations and stocks eligible for investment under these rules. As of the date the loan is made, it shall not exceed in amount eighty percent of the market value of the collateral pledged. No such loan shall be made for the purpose of providing funds to purchase or carry stocks registered on a national securities exchange.

(2) Funds of a CCO may be invested in loans secured by personal property or fixtures if such loan is:

(a) In connection with a loan on the security of real property or a leasehold as provided in OAR 410-141-5110;

(b) In an amount not exceeding twenty percent of the amount loaned on the real property or leasehold;

(d) Secured by a security interest which constitutes a first lien, except for taxes not then delinquent, on tangible, permanent personal property of the borrower kept and used on the premises, other than stocks of goods held for sale or transfer in the ordinary course of business or items which by normal use shall be consumed or depleted during the period of the loan; and

(e) In an amount, the ratio of which to the value of the security does not exceed the ratio of the companion loan to the value of the real property or leasehold.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5130 ASSET VALUATION AND PERMITTED INVESTMENTS: Investments; Certain Obligations, Property, Loans and Other Specified Items

Funds of a CCO may be invested in the following:

(1) Obligations secured by a mortgage or deed of trust payment of which is guaranteed by a policy of mortgage insurance.

(2) Obligations issued, assumed or guaranteed by the International Bank for Reconstruction and Development.

(3) Bank and bankers' acceptances and other bills of exchange of the kind and nature made eligible by law for purchase in the open market by federal reserve banks.

(4) Deposits, certificates of deposits, accounts or savings or certificate shares or accounts of or in banks, trust companies, savings and loan associations or building and loan associations insured with the Federal Deposit Insurance Corporation or qualified to do business under the laws of this state.

(5) Obligations issued by trustees or receivers of a corporation created or existing under the laws of a sovereign which, or the assets of which, are being administered under the direction of a court having jurisdiction if the obligation is adequately secured as to principal and interest.

(6) Transportation equipment used wholly or in part within a sovereign, or adequately secured trust certificates of participation or similar obligations or contracts evidencing an interest in such transportation equipment, where the investor is entitled to receive a determined or determinable portion of rental, purchase or other obligatory payments for use or purchase of the equipment.

(7) Purchase contracts or lease-purchase agreements executed under the Federal Public Buildings Purchase Contract Act of 1954, or the Post Office Department Property Act of 1954.

(8) Stock of the Federal Home Loan Bank to the extent of the minimum required by the Federal Home Loan Bank Act. A CCO acquiring such stock may exercise all rights and powers given to members under such Act, including but not by way of limitation the right to obtain advances or borrow money from such bank and to pledge collateral as security therefor.

(9) Obligations issued, assumed or guaranteed by the Inter-American Development Bank.

(10) Obligations issued, assumed or guaranteed by the Asian Development Bank.

(11) Obligations issued, assumed or guaranteed by the African Development Bank.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5135 ASSET VALUATION AND PERMITTED INVESTMENTS: Personal Property; Protection of Investment Property; Custom

(1) A CCO may acquire and retain personal property received as a dividend, gift or devise, or pursuant to a lawful plan of merger, consolidation or reorganization or bona fide agreement of bulk reinsurance, or in satisfaction or liquidation of an obligation, or in exchange or part payment for real or personal property previously owned or to protect or enhance such property.

(2) A CCO may make purchases or loan sums necessary to protect, preserve or enhance investment property, real or personal, which it is otherwise authorized to acquire or hold.

(3) The Authority shall allow as assets in any determination of the financial condition of the CCO only such property or investments acquired or retained under this section as are consistent with the customary operations of a CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5140 ASSET VALUATION AND PERMITTED INVESTMENTS: “Prudent Investor” Standard

(1) Funds of a CCO may be invested in a manner not expressly prohibited under OAR 410-141-5145 and OAR 410-141-5165 provided such investments are made in the exercise of the judgment and care under the circumstances then prevailing which investors of prudence, discretion and intelligence exercise in the management of their own affairs not in regard to speculation but in regard to the permanent disposition of their funds, considering the probable income as well as the probable safety of their capital.

(2) Funds invested under this section shall not exceed the lesser of seven and one-half percent of the CCO's assets or the excess of the CCO's assets over all liabilities and required capitalization.

(3) If the Authority has reason to believe that loans or investments made pursuant to this section are not adequately secured or are not yielding an income the Authority may direct the CCO to report under oath the amount of such loans or investments, the security therefor and its market value.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5145 ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Conduct by Directors, Trustees, Officers, Agents or Employees

(1) Except in the case of the issuance or sale of the CCO's securities, as approved by a majority of the disinterested members of the CCO’s Board, or failing such majority by the shareholders, a director, trustee, officer, agent or employee, or spouse or relative thereof, shall not receive any fee, commission, compensation or other valuable consideration whatsoever, directly or indirectly, for aiding, promoting or assisting:

(a) The planning, preparing or executing of an activity described in OAR 410-141-5160; or

(b) The planning, preparing or executing of any plan for the issuance, sale or acquisition of shares or other securities of the CCO for any purpose.

(2) Except as provided in subsections (4) and (5) of this section, a director, trustee or officer of a CCO shall not:

(a) Accept any money or thing of value for negotiating, procuring, recommending or aiding in:

(A) The purchase or sale of property by the CCO; or

(B) The making of a loan to or from the CCO.

(b) Have a pecuniary interest, whether as principal, agent or beneficiary, in a purchase, sale or loan under paragraph (a) of this subsection.

(3) Except as provided in subsections (4) and (5) of this section, a CCO shall not do any of the following:

(a) Pay any money or thing of value to a director, trustee or officer of the CCO for negotiating, procuring, recommending or aiding in:

(A) The purchase or sale of property by the CCO; or

(B) The making of a loan to or from the CCO.

(b) Make a loan to a director, trustee or officer of the CCO.

(d) Guarantee any financial obligations of a director, trustee or officer of the CCO.

(4) A CCO may contract, or otherwise enter into a transaction, for the provision of goods or services to the CCO in the normal course of business with a director, trustee or officer, or a partnership or corporation in which a director, trustee or officer has, directly or indirectly, a proprietary interest in excess of five percent, if the interest of the director, trustee or officer is fully disclosed to the CCO’s Board and the CCO’s board thereafter approves and authorizes the contract or transaction by a vote sufficient for the purpose without counting the vote of the interested person.

(5) The prohibitions set forth in this section shall not apply to or affect:

(a) The payment to any director, officer or trustee of reasonable compensation, whether based in whole or in part upon commission or otherwise;

(b) The payment of a fee to any approved person for legal or other specialized or professional services rendered to the CCO and approved by the CCO’s Board;

(c) The making of loans or advances to agents or other employees of a CCO as required or as is expedient in the conduct of its business;

(d) The issuance of a debt obligation by a CCO to a director, officer or trustee of the CCO; and

(e) The advance of expenses to a director, officer or trustee for travel or other related business activities of the CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5150 ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Funds in Obligations That Are Not Investment Quality; Percentage of Assets

(1) A CCO may acquire or hold obligations that are not investment grade only as provided in this section.

(2) For purposes of this section, an obligation is not investment grade if the obligation is either of the following:

(a) A “medium grade obligation”, which means an obligation that is rated three by the SVO;

(b) A “lower grade obligation”, which means an obligation that is rated four, five or six by SVO.

(3) A CCO shall not acquire, directly or indirectly, any medium grade or lower grade obligation of any person if, after given effect to the acquisition, the aggregate amount of all medium grade and lower grade obligations then held by the CCO would exceed 20% of its allowed assets. For purposes of this section, the aggregate amount of medium grade and lower grade obligations shall be the aggregate value of the obligations as set forth in the most recent financial statement required by, and filed with, the Authority.

(4) In addition to the prohibition in subsection (3) on the aggregate amount of medium grade and lower grade obligations, a CCO shall not acquire or hold:

(a) More than ten percent of its allowed assets in obligations rated four, five or six by the SVO;

(b) More than three percent of its allowed assets in obligations rated five or six by the SVO;

(5) Attaining the limit of any one category under subsection (4) does not preclude a CCO from acquiring or holding obligations in other categories, subject to the specific and multi-category limits of this section.

(6) The following prohibitions apply to investments in lower grade obligations and medium grade obligations issued, guaranteed or insured by any one person:

(a) A CCO shall not acquire or hold more than an aggregate of one percent of its allowed assets in medium grade obligations issued, guaranteed or insured by any one person;

(b) A CCO shall not acquire or hold more than one-half of one percent of its allowed assets in lower grade obligations issued, guaranteed or insured by any one person;

(c) In addition to the prohibitions in subsections (a) and (b) of this section, a CCO shall not acquire or hold more than one percent of its allowed assets in any medium or lower grade obligations issued, guaranteed or insured by any one person.

(7) This section does not prohibit a CCO from doing any of the following:

(a) Acquiring any obligation that the CCO committed prior to the effective date of this section to acquire if the CCO would have been permitted to acquire the obligation when the CCO made the commitment;

(b) Acquiring an obligation as a result of a restructuring of a medium or lower grade obligation already held.

(8) A CCO may acquire a medium or lower grade obligation of a person in which the CCO already has one or more medium or lower grade obligations if the obligation is acquired in order to protect an investment previously made in the obligations of the person. All such acquired obligations, however, shall not exceed one-half of one percent of the CCO's allowed assets.

(9) The board of directors of a CCO that acquires, hold or invests, directly or indirectly, more than two percent of its allowed assets in medium grade and lower grade obligations shall adopt a written plan for the making of such investments. The plan shall contain guidelines with respect to the quality of the issues invested in as well as diversification standards. The diversification standards shall at least include standards regarding the issuer, industry, duration, liquidity and geographic location.

(10) A CCO shall not acquire any lower grade or medium grade obligation that in whole or in part exceed the applicable limitation established in this section. The requirement under this section does not apply to the acquisition of an obligation to which subsection (7) applies.

(11) If an obligation held by a CCO is of investment grade when acquired but subsequently becomes a medium grade or lower grade obligation, and that event causes the obligations of the CCO to exceed an applicable limit established under this section, the CCO shall not count the excess as an allowed asset. A CCO shall not hold any excess ascribable to deterioration of an obligation as described in this section longer than a continuous period of three years during which the obligation is a medium or lower grade obligation, except with the consent of the Authority.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5155 ASSET VALUATION AND PERMITTED INVESTMENTS: Approval by Board

(1) The investment policy shall be approved by the CCO’s Board or a committee thereof charged with the duty of investing the funds of the CCO.

(2) Deposits shall be made in banks or banking institutions approved by the CCO’s Board.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5160 ASSET VALUATION AND PERMITTED INVESTMENTS: Record of Investments

As to each investment, a CCO shall make a written record in permanent form, signed by a person authorized by the CCO’s Board or by a committee thereof charged with the duty of investing the funds. The record shall show the authorization and approval of the investment and in addition shall contain:

(1) In the case of mortgage loans:

(a) The name of the borrower;

(b) The location and legal description of the property;

(c) A physical description and the appraised value of the security as determined by a competent and qualified appraiser; and

(d) The amount of the loan, rate of interest and terms of repayment.

(2) In the case of obligations:

(a) The name of the obligor;

(b) A description of the security and record of earnings;

(d) The maturity and yield based upon the purchase price.

(3) In the case of corporate stocks:

(a) The name of the issuing corporation;

(b) The record of earnings and of dividends paid for the preceding three years for preferred stock and for the preceding five years for common stock;

(d) The exchange, if any, on which the stock is listed; and

(e) The amount invested and the number of shares acquired and held.

(4) In the case of real estate, leaseholds or vendors' interests under contracts of sale therein:

(a) The location and legal description of the property;

(b) A physical description and the appraised value of the property and interest therein;

(d) The amount of any lien known to be against the property;

(e) If of a leasehold, the terms of the outstanding lease; and

(f) If a vendor's interest under a contract of sale, the terms and status of payments under the contract.

(5) In the case of all investments:

(a) The amount of any expenses and commissions incurred on account of the investment or loan and by whom and to whom payable if not covered by contracts with mortgage loan representatives or correspondents that are part of the CCO's records; and

(b) The name of any director, trustee or officer of the CCO, having a direct, indirect or contingent interest in the loan, security or property, or who would derive, directly or indirectly, any benefit therefrom, and the nature of such interest or benefit.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5165 ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Investments

(1) A CCO shall not make investments:

(a) Which at the time of purchase or acquisition are not interest-bearing or dividend or income-paying, or are in default in any respect; or

(b) From which the CCO is not entitled to receive for its exclusive account and benefit the interest, dividends or income.

(2) Subsection (1)(a) of this section shall not apply to property acquired under OAR 410-141-5115, OAR 410-141-5135 or OAR 410-141-5140 if the property is acquired with the intent and expectation that it shall be income-producing.

(3) A CCO shall not have any combination of investments in or secured by the stocks, obligations, and property of one person, corporation or political subdivision in excess of ten percent of the CCO's assets, nor shall it invest more than ten percent of its assets in a single parcel of real property or in any other single investment. This subsection does not apply to investments in, or loans upon, the security of the general obligations of a sovereign.

(4) A CCO shall not invest its funds in any investment or security found by the Authority to be designed to evade any prohibition of state or federal law.

(5) The Authority may issue a determination requiring the disposal of an investment which the Authority finds to be made or retained in violation of state or federal law, or of an investment which the Authority, for good cause, determines to be prejudicial to, or to impair the security of, the stockholders or Members of the CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5170 CAPITALIZATION: Capital and Surplus

(1) CCO shall possess and thereafter maintain capital or surplus or any combination thereof equal to no less than $2.5 million.

(2) Notwithstanding a CCO’s compliance with subsection (1) a CCO shall at all times also comply with the risk-based capital standards set forth at OAR 410-141- 5295 to 5320.

(3) For the protection of the public, the Authority may require a CCO to possess and maintain capital or surplus, or any combination thereof, in excess of the amounts otherwise required under this section, owing to the type, volume and nature of business transacted by the CCO, if the Authority determines under OAR 410-141-5175 that the greater amount is necessary for maintaining the CCO’s solvency in accordance with OAR 410-141-5195 et seq For the purpose of determining the reasonableness and adequacy of a CCO's capital and surplus, the Authority may consider the net effect of factors bearing on the financial condition of the CCO including but not limited to:

(a) The size of the CCO, as measured by its assets, capital and surplus, reserves, capitated revenue and other appropriate criteria.

(b) The number of Members covered by the CCO.

(d) The nature and extent of the reinsurance program of the CCO.

(e) The quality, diversification and liquidity of the investment portfolio of the CCO.

(f) The recent past and projected future trend in the size of the investment portfolio of the CCO.

(g) The combined capital and surplus maintained by comparable CCOs.

(h) The adequacy of the reserves of the CCO.

(i) The quality and liquidity of investments in affiliates. The Authority may treat any such investment as a disallowed asset for purposes of determining the adequacy of combined capital and surplus whenever in the judgment of the Authority the investment so warrants.

(j) The quality of the earnings of the CCO and the extent to which the reported earnings include extraordinary items.

(4) In comparing the capital and surplus maintained by other CCOs, the Authority shall consider the extent to which each of such factors varies from CCO to CCO. In determining the quality and liquidity of investments in subsidiaries, the Authority shall consider the individual subsidiary and may discount or disallow its valuation to the extent that the individual investments so warrant.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5175 CAPITALIZATION: Impaired Capital and Surplus

(1) If the Authority determines in accordance with OAR 410-141-5195 to 410-141-5220 that a CCO’s reserves, however calculated or estimated, are inadequate, the Authority may require the CCO to maintain reserves in such additional amount as is needed to make them adequate.

(2) Whenever the Authority determines from any showing or statement made to the Authority or from any examination made by the Authority that the assets of a CCO are less than its liabilities plus required capitalization, the Authority may proceed immediately under the provisions of ORS 415.203 or the Authority may allow the CCO a period of time, not to exceed ninety (90) days, in which to make good the amount of the impairment with cash or authorized investments.

(3) If the amount of any such impairment is not made good within the time prescribed by the Authority under subsection (2) of this section, the Authority shall proceed under the provisions of ORS 415.203.

(4) An order directing a CCO to cure an impairment shall be confidential for such time as the Authority considers proper but not exceeding the time prescribed by the Authority for making the amount of the impairment good. If the Authority determines that the public interest in disclosure outweighs the public interest in protecting the solvency of the CCO, the Authority may make the order available for public inspection.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5180 CAPITALIZATION: Dividend and Distribution Restrictions

(1) Unless prior written approval of the Authority is first obtained pursuant to (2), a CCO shall not:

(a) Make any distribution of assets by dividend or other distribution to shareholders, equity members, parent companies or any related parties that would cause the CCO’s capital and surplus to fall below the prescribed minimum under OAR 410-141-5170.

(b) Reduce its total adjusted capital by partial distribution of its assets, by payment in the form of a dividend or otherwise to shareholders, equity members, parent companies or any related parties below an amount equal to three hundred (300) percent of the CCO’s authorized control level risk-based capital, as defined in and calculated pursuant to OAR 410-141-5215.

(c) Declare or pay dividends to shareholders, equity members, parent companies or any related parties other than from earned surplus. For purposes of this subsection, “earned surplus” does not include surplus arising from unrealized capital gains or revaluation of assets.

(d) Declare or pay an extraordinary dividend or distribution to shareholders, equity members, parent companies or any related parties. A dividend or dividend is “extraordinary” for purposes of this subsection if it exceeds an amount equal to the aggregate of the CCO’s net after-tax income for the prior three calendar years, less any dividends or distributions paid during the prior two calendar years and the current year. “Extraordinary dividend or distribution” does not include pro rata distributions of any class of the CCO's own securities.

(2) A CCO shall notify the Authority no later than twenty (20) business days prior to taking any action pursuant to subsection (1). The Authority shall approve or disapprove such payment within twenty (20) business days and the CCO shall not pay or make any extraordinary dividend or distribution unless or until the Authority provides written approval of such payment to the CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 55-2020, minor correction filed 10/01/2020, effective 10/01/2020
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5185 CAPITALIZATION: Restricted Reserve Account

(1) A CCO shall establish a Restricted Reserve Account and maintain sufficient Restricted Reserve Funds in the Restricted Reserve Account to meet the Authority’s Primary Reserve and Secondary Reserve requirements. Restricted Reserve Funds shall be held for the purpose of:

(a) Making payments to providers in the event of the CCO’s insolvency; and

(b) Assuring the CCO’s performance in the event its CCO Contract is terminated.

(2) A CCO’s Primary Reserve and Secondary Reserve balances shall be determined by calculating the CCO’s average monthly medical expense incurred, unless the Authority agrees upon an exception to the below calculations:

(a) If a CCO has submitted quarterly financial statements for the current quarter and the prior three quarters, the average monthly medical expense incurred shall be derived by adding together the “total hospital and medical” expense (NAIC statement of revenue and expenses) for the prior four quarters and dividing by 12;

(b) A newly formed CCO shall use an average of hospital and medical expense projected for the first four quarters of operation;

(d) The Authority may allow a CCO to adjust its calculation of its average monthly medical expenses by excluding any commercial line of business or any Medicare line of business from the “total hospital and medical” expense.

(3) The amount a CCO must deposit and maintain in its Restricted Reserve Account shall be calculated as follows:

(a) If a CCO’s average monthly medical expense incurred is less than or equal to $250,000, an amount equal to the average monthly medical expense incurred shall be deposited into, and maintained in, the Restricted Reserve Account. This amount shall be referred to as the CCO’s “Primary Reserve” and the CCO shall have no “Secondary Reserve” (hereinafter defined) until such time as the CCO’s average monthly medical expense exceeds $250,000;

(b) If a CCO’s average monthly medical expense is greater than $250,000, an amount equal to fifty (50) percent of the difference between the average monthly medical expense and the Primary Reserve balance of $250,000 shall be deposited into, and maintained in, the Restricted Reserve Account. This additional amount is referred to as the CCO’s “Secondary Reserve;”

(c) A CCO’s Primary Reserve and, if applicable, its Secondary Reserve shall be recalculated and the balance of the Restricted Reserve Account shall be adjusted accordingly each quarter based upon the CCO’s then current average monthly medical expense;

(d) The Authority may allow a CCO to adjust its calculation of its Primary Reserve and Secondary Reserve, based on the CCO’s use of value-based payments.

(4) A CCO shall establish its Restricted Reserve Account with a third-party financial institution for the purpose of holding the CCO’s Primary Reserve and Secondary Reserve.

(5) The Authority’s Model Depository Agreement shall be used by the CCO to establish its Restricted Reserve Account. CCOs shall request the model depository agreement form from the Authority. CCOs shall submit the model depository agreement to the Authority at the time of the CCO’s application to the Authority under OAR 410-141-3700 and the model depository agreement shall remain in effect throughout the period of time that the CCO Contract is in effect. The model depository agreement cannot be changed without the Authority’s prior written approval.

(6) The CCO shall not withdraw funds, change third party financial institutions, or change account numbers within the Restricted Reserve Account without the prior written consent of the Authority.

(7) A CCO shall submit a copy of the model depository agreement at the time of application. If a CCO requests and receives written authorization from the Authority to make a change to its existing Restricted Reserve Account, the CCO shall submit a model depository agreement reflecting the changes to the Authority within fifteen (15) business days of the date of the change.

(8) The following instruments are considered eligible deposits for the purposes of a CCO’s Primary Reserve and Secondary Reserve:

(a) Cash;

(b) Certificates of Deposit;

(d) Amply secured obligations of a political subdivision as determined by the Authority to be acceptable.

(9) If a CCO has multiple CCO Contracts or agreements with the Authority, separate Restricted Reserve Accounts shall be maintained for each CCO Contract and agreement, except as required in this subsection. Separate Restricted Reserve Accounts shall not be required for state-funded services and Oregon Health Plan contracts. However, the CCO shall be obligated to maintain actuarially sound and sufficient aggregate loss reserves for all its contractual liabilities, including both contractual liabilities that are supported by a Restricted Reserve Account and those which are not so supported.

(10) CCOs that enter into Sub-Capitation Arrangements for any portion of the health care services covered by the CCO’s agreement with the Authority may require that the Capitated Subcontractor establish, fund and maintain a Restricted Reserve Account and Restricted Reserve Funds for the Capitated Subcontractor's portion of the risk assumed. Alternatively, the CCO may elect to establish, fund and maintain a single Restricted Reserve Account for all risk assumed under the agreement with the Authority (including the portion of those risks assumed by the Capitated Subcontractor). In either event, the CCO shall assure that the aggregate of the Restricted Reserve Account(s) and Restricted Reserve Funds comply with the requirements of this section.

(11) All the requirements of this section in respect of a CCO’s Restricted Reserve Account shall respectively apply to a Restricted Reserve Account established, funded and maintained by a Capitated Subcontractor under subsection (10).

(12) If a Restricted Reserve Fund of a CCO is held in a combined account or pool with other entities, the CCO and its subcontractors, as applicable, shall provide a statement from the pool or account manager or custodian confirming that the proceeds of the Restricted Reserve Fund shall be available for payment to the CCO and the Authority, on demand, and that no other payee has the contractual right to withdraw the proceeds of the Restricted Reserve Account under or pursuant to the agreement(s) governing administration of the Restricted Reserve Account.

(13) If a CCO wishes to withdraw proceeds from its Restricted Reserve Account in order to cover services under its CCO Contract, the CCO shall provide advance notice to the Authority of the amount to be withdrawn, the reason for withdrawal, when and how the Restricted Reserve Fund shall be replenished, and measures to avoid the need for future withdrawals from the Restricted Reserve Account. A CCO shall notify the Authority no later than twenty (20) business days prior to withdrawing proceeds from its Restricted Reserve Account pursuant to subsection. The Authority shall approve or disapprove such payment within twenty (20) business days. A CCO shall not withdraw such proceeds without the prior written approval of the Authority.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5186 CAPITALIZATION: Restricted Reserve Account—Permitted Investments in Obligations with Political Subdivisions; Public Supported Housing

(1) With prior written approval from the Authority, a CCO may invest up to twenty-five (25) percent of its Primary Reserve and Secondary Reserve with one or more public housing authorities created under ORS 456.055 to 456.235 and governed by a county in the CCO’s service area.

(a) The housing authority(ies) must address a documented social determinant of health and equity need, as outlined in OAR 410-141-3735, for that community;

(b) The CCO shall complete and file with the Authority a Form D as described and required under OAR 410-141-5320 for each housing authority that the CCO contracts with under this section;

(c) The CCO shall complete and file with the Authority the Model Depository Agreement specific to any obligation described in this section that shall not be held with a third-party financial institution.

(2) The obligation shall be supported by an agreement between the CCO and the housing authority.

(a) The agreement shall describe the use of the funds provided (e.g. newly constructed vs. purchased; public housing vs. affordable housing vs. mixed income housing; owned vs. operated; type of housing unit such as single-family dwellings, multifamily dwellings, emergency shelters, dwelling accommodations, living accommodations, manufactured dwelling parks, residential units) and how the funds shall address a documented social determinant of health need for that community;

(b) The agreement shall require and describe financial reporting requirements including but not limited to audited financial statements;

(3) The obligation shall be secured through written guarantees by a regulated guarantor who is adequately capitalized. The guarantor’s adequate capitalization is demonstrated through financial reports submitted at least annually to, and evaluated by, either the Authority or a state or federal insurance or bank regulatory agency.

(a) The guarantee shall be unconditional and absolute for the full and prompt payment and performance of all obligations under the promissory note;

(b) The guarantee shall remain in full force and effect and be binding upon guarantors until the promissory note is paid and performed in full;

(c) A draft copy of the guarantee, together with the most recent audited financial statement and regulatory examination of the guarantor, shall be included with the Form D submission.

(4) The obligation shall be supported by a promissory note between the housing authority and the CCO.

(a) The promissory note shall mature no later than the date of the end of the current CCO Contract;

(b) The promissory note may be extended in the event that the CCO Contract is extended;

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 56-2021, adopt filed 12/30/2021, effective 01/01/2022

Or. Admin. R. 410-141-5190 CAPITALIZATION: Surplus Notes

(1) With the prior approval of the Authority, a CCO may issue one or more surplus notes in order to secure funding needed to comply with minimum capital and surplus requirements and/or minimum risk-based capital requirements under these rules, or otherwise to provide additional funding required for the CCO’s operations.

(2) Approval by the Authority of the issuance and sale of a surplus note by a CCO, including the form and terms of the surplus note and the purchaser of the surplus note, is required and shall be at the sole discretion of the Authority.

(3) The issuance and sale of a surplus note, and the form and terms of the surplus note, shall comply with the standards for the issuance of surplus notes set forth in the Accounting Practices and Procedures Manual published by the NAIC, as well as the following requirements:

(a) A surplus note shall be sold only in return for cash or marketable securities having readily determinable values and liquidity satisfactory to the Authority.

(b) Commissions, promotion expenses or finders’ fees may not be paid in connection with a surplus note sale except for commissions, expenses and fees customarily incurred within the context of public or private placement offerings underwritten by an investment banking or similar entity.

(c) Payment of principal or interest on a surplus note may not be made without the prior written approval of the Authority. The issuer shall provide the Authority with written notice at least twenty (20) business days prior to the intended date of the payment of principal or interest on a surplus note or such shorter period as the Authority may permit.

(d) Payment of principal or interest on a surplus note shall be subordinated to payment of all other liabilities of the issuer.

(e) Payment of interest on a surplus note may be made only from the unassigned funds of the issuer.

(f) Surplus notes shall not be assignable or negotiable without the prior written approval of the Authority.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5195 CAPITALIZATION: Risk-based Capital (RBC) Definitions

As used in OAR 410-141-5195 to 410-141-5220:

(1) "Authorized Control Level RBC" means the number determined under the risk-based capital formula in accordance with the RBC Instructions.

(2) "Company Action Level RBC" means, with respect to any CCO, the product of 2.0 (200 percent) and the CCO’s Authorized Control Level RBC.

(3) “Corrective Order” means an order entered by the Authority under specifying corrective actions the Authority determines are required of a CCO in respect of its Total Adjusted Capital and its RBC Level.

(4) "Mandatory Control Level RBC" means the product of .70 (70 percent) and the CCO’s authorized control level RBC.

(5) "RBC Instructions" means the RBC Report form and including risk-based capital instructions adopted by the NAIC, as such form and instructions may be amended by the NAIC from time to time and identified by the Authority to be applicable for the reporting period. The applicable RBC Instructions prescribed by the Director referred to in this rule are available for inspection at the office of the Authority. Any person interested in inspecting RBC Instructions may contact the Authority at actuarial.services@oha.oregon.gov.

(6) "RBC Level" means a CCO’s Company Action Level RBC, Regulatory Action Level RBC, Authorized Control Level RBC or Mandatory Control Level RBC.

(7) "RBC Plan" means a comprehensive financial plan containing the elements specified in OAR 410-141-5195 to 410-141-5220. If the Authority rejects the RBC Plan and it is revised by the CCO with or without the Authority's recommendation, the plan shall be called the "revised RBC Plan."

(8) "RBC Report" means the report required by OAR 410-141-5200.

(9) "Regulatory Action Level RBC" means the product of 1.5 (150 percent) and the CCO’s Authorized Control Level RBC.

(10) "Total Adjusted Capital" means the sum of:

(a) A CCO’s capital and surplus as determined in accordance with the Statutory Accounting Principles applicable to the annual financial statements required to be filed under OAR 410-141-5015; and

(b) Such other items, if any, as the RBC instructions may provide.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5200 CAPITALIZATION: RBC Reports

(1) On or before April 30 of each year, a CCO shall prepare and submit to the Authority a report of its Total Adjusted Capital and its RBC Levels as of the end of the calendar year immediately preceding, in a form and containing such information as are required by the RBC instructions. A CCO shall file its RBC Report with the NAIC in accordance with the RBC instructions. The CCO shall report in its annual financial statement its Total Adjusted Capital and its Authorized Control Level RBC as calculated in its RBC Report. A CCO’s RBC Report will be considered confidential and shall not be made available to the public.

(2) A CCO’s Total Adjusted Capital shall be determined in accordance with the formula set forth in the RBC instructions. The formula shall take the following factors into account (and may adjust for the covariance between such factors) determined in each case by applying the factors in the manner set forth in the RBC instructions:

(a) Asset risk;

(b) Credit risk;

(d) All other business risks and such other relevant risks as are set forth in the RBC instructions.

(3) A substantial excess of Total Adjusted Capital over Company Action Level RBC is desirable. Accordingly, a CCO should seek to maintain Total Adjusted Capital that exceeds the CCO’s Company Action Level RBC. Additional capital is used and useful in the business of a risk-bearing entity and helps to secure a CCO against various risks inherent in, or affecting, the business of a CCO and not accounted for or only partially measured by the risk-based capital requirements contained in OAR 410-141-5195 to 410-141-5220. The Authority recommends that a CCO endeavor to maintain its Total Adjusted Capital at no less than three hundred (300) percent of its Authorized Control Level RBC.

(4) If a CCO files an RBC Report that in the judgment of the Authority is inaccurate, then the Authority shall adjust the RBC Report to correct the inaccuracy and shall notify the CCO of the adjustment. The notice shall contain a statement of the reason for the adjustment. An RBC Report as so adjusted is referred to as an "adjusted RBC Report."

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5205 CAPITALIZATION: Company Action Level Event

(1) "Company Action Level Event" means any of the following events:

(a) The filing of an RBC Report by a CCO that indicates that the CCO’s Total Adjusted Capital is greater than or equal to its Regulatory Action Level RBC but less than its Company Action Level RBC. The CCO shall provide prompt written notice to the Authority, together with an RBC Report, if it learns that the CCO is the subject of a Company Action Level Event.

(b) Notification by the Authority to the CCO of an adjusted RBC Report that indicates an event in subsection (a), if the CCO does not challenge the adjusted RBC Report.

(c) If a CCO challenges an adjusted RBC Report according to the terms of the CCO Contract that indicates the event in subsection (a), notification by the Authority to the CCO that the Authority has rejected the CCO’s challenge.

(2) In the event of a Company Action Level Event, the CCO shall prepare and submit to the Authority an RBC Plan that:

(a) Identifies the conditions that caused or contributed to the Company Action Level Event.

(b) Contains proposed corrective actions that the CCO intends to take and that are expected to result in the elimination of the Company Action Level Event.

(c) Provides projections of the CCO’s financial results in the current year and at least two (2) succeeding years, both in the absence of the proposed corrective actions and giving effect to the proposed corrective actions, including projections of statutory balance sheets, operating income, net income, capital and surplus, and RBC levels.

(d) Identifies the key assumptions impacting the CCO’s projections and the sensitivity of the projections to those assumptions.

(e) Identifies the quality of, and problems associated with, the CCO’s business, including but not limited to its assets, anticipated business growth and associated surplus strain, extraordinary exposure to risk, mix of business and use of reinsurance, if any.

(3) The RBC Plan shall be submitted:

(a) Within thirty (30) days of the Company Action Level Event; or

(b) Within thirty (30) days after notification to the CCO that the Authority has rejected the CCO’s challenge, if the CCO challenges an adjusted RBC Report according to the terms of the CCO Contract which indicated a Company Action Level Event.

(4) Within sixty (60) days after the submission by a CCO of an RBC Plan to the Authority, the Authority shall notify the CCO whether the RBC Plan shall be implemented or is, in the judgment of the Authority, unsatisfactory. If the Authority determines the RBC Plan is unsatisfactory, the notification to the CCO shall set forth the reasons for the determination and may set forth proposed revisions that will render the RBC Plan satisfactory, in the judgment of the Authority. Upon notification from the Authority, the CCO shall prepare a revised RBC Plan, which may incorporate by reference any revisions proposed by the Authority, and shall submit the revised RBC Plan to the Authority:

(a) Within fourty-five (45) days after the notification from the Authority; or

(b) Within fourty-five (45) days after a notification to the CCO that the Authority has, rejected the CCO’s challenge, if the CCO challenges the notification from the Authority under this section according to the terms of the CCO Contract.

(5) In the event of a notification by the Authority to a CCO that the CCO’s RBC Plan or revised RBC Plan is unsatisfactory, the Authority may at the Authority's discretion, subject to the CCO’s right to a hearing under this section, specify in the notification that the notification constitutes a Regulatory Action Level Event.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5210 CAPITALIZATION: Regulatory Action Level Event

(1) "Regulatory Action Level Event" means, with respect to a CCO, any of the following events:

(a) The filing of an RBC Report by the CCO that indicates that the CCO's Total Adjusted Capital is greater than or equal to its Authorized Control Level RBC but less than its Regulatory Action Level RBC. The CCO shall provide prompt written notice to the Authority, together with an RBC Report, if it learns that the CCO is the subject of a Regulatory Action Level Event.

(b) Notification by the Authority to a CCO of an adjusted RBC Report that indicates the event in subsection (a), if the CCO does not challenge the adjusted RBC Report.

(c) If the CCO challenges an adjusted RBC Report, according to the terms of the CCO Contract, that indicates the event in subsection (a), the notification by the Authority to the CCO that the Authority has rejected the CCO's challenge.

(d) The failure of the CCO to file an RBC Report by the filing date, unless the CCO has provided an explanation for the failure that is satisfactory to the Authority and has cured the failure within ten days after the filing date.

(e) The failure of the CCO to submit an RBC Plan to the Authority within the time period set forth in this section.

(f) Notification by the Authority to the CCO that:

(A) The RBC Plan or revised RBC Plan submitted by the CCO under this section is, in the judgment of the Authority, unsatisfactory; and

(B) The CCO has not challenged the determination.

(g) If the CCO challenges a determination by the Authority according to the terms of the CCO Contract, the notification by the Authority to the CCO that the Authority has rejected the challenge;

(h) Notification by the Authority to the CCO that the CCO has failed to adhere to its RBC Plan or revised RBC Plan, but only if the failure has a substantial adverse effect on the ability of the CCO to eliminate the Company Action Level Event in accordance with its RBC Plan or revised RBC Plan and the Authority has so stated in the notification, if the CCO has not challenged the determination; or

(i) If the CCO challenges a determination by the Authority, according to the terms of the CCO Contract, the notification by the Authority to the CCO that the Authority has rejected the challenge.

(2) In the event of a Regulatory Action Level Event, the Authority may take some or all of the following actions:

(a) Require the CCO to prepare and submit an RBC Plan or, if applicable, a revised RBC Plan.

(b) Perform such examination or analysis as the Authority deems necessary of the assets, liabilities and operations of the CCO including a review of its RBC Plan or revised RBC Plan.

(c) Subsequent to the examination or analysis, issue a Corrective Order specifying such corrective actions as the Authority shall determine are required.

(d) Prohibit or limit enrollments until further notice.

(e) Require the CCO to provide monthly financial statements.

(3) In determining corrective actions, the Authority may take into account factors the Authority deems relevant with respect to the CCO based upon the Authority's examination or analysis of the assets, liabilities and operations of the CCO, including, but not limited to, the results of any sensitivity tests undertaken pursuant to the RBC instructions. The RBC Plan or revised RBC Plan shall be submitted:

(a) Within thirty (30) days after the occurrence of the Regulatory Action Level Event; or

(b) Within thirty (30) days after the notification to the CCO that the Authority has, after a hearing, rejected the CCO's challenge.

(4) The Authority may retain actuaries and investment experts and other consultants as may be necessary in the judgment of the Authority to review the CCO's RBC Plan or revised RBC Plan, examine or analyze the assets, liabilities and operations (including contractual relationships) of the CCO and formulate a Corrective Order with respect to the CCO. The fees, costs and expenses relating to consultants shall be borne by the affected CCO or such other party as directed by the Authority.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5215 CAPITALIZATION: Authorized Control Level Event

(1) "Authorized Control Level Event" means any of the following events:

(a) The filing of an RBC Report by the CCO that indicates that the CCO's Total Adjusted Capital is greater than or equal to its Mandatory Control Level RBC but less than its Authorized Control Level RBC. The CCO shall provide prompt written notice to the Authority, together with an RBC Report, if it learns that the CCO is the subject of an Authorized Control Level Event;

(b) The notification by the Authority to the CCO of an adjusted RBC Report that indicates the event in subsection (a), if the CCO does not challenge the adjusted RBC Report;

(c) If the CCO challenges an adjusted RBC Report that indicates the event in subsection (a), according to the terms of the CCO Contract, notification by the Authority to the CCO that the Authority has rejected the CCO's challenge;

(d) The failure of the CCO to respond, in a manner satisfactory to the Authority, to a Corrective Order if the CCO has not challenged the Corrective Order;

(e) If the CCO has challenged a Corrective Order according to the terms of the CCO Contract and the Authority has rejected the challenge or modified the Corrective Order, the failure of the CCO to respond, in a manner satisfactory to the Authority, to the Corrective Order subsequent to rejection or modification by the Authority.

(2) In the event of an Authorized Control Level Event, the Authority may take any or all of the following actions:

(a) Take such actions as are allowed under OAR 410-141-5210 regarding a CCO with respect to which a Regulatory Action Level Event has occurred;

(b) If the Authority deems it to be in the best interests of the Members and creditors of the CCO and of the public, the Authority may:

(A) Place the CCO under regulatory control and/or apply to have the CCO made the subject of court-ordered conservancy proceedings pursuant to ORS 415.203 to 415.400;

(B) Terminate the CCO Contract(s) with the Authority and cause the Members covered by the CCO to be transferred to one or more other CCOs.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5220 CAPITALIZATION: Mandatory Control Level Event

(1) "Mandatory Control Level Event" means any of the following events:

(a) The filing of an RBC Report that indicates that the CCO's Total Adjusted Capital is less than its Mandatory Control Level RBC. The CCO shall provide prompt written notice to the Authority, together with an RBC Report, if it learns that the CCO is the subject of a Mandatory Control Level Event.

(b) Notification by the Authority to the CCO of an adjusted RBC Report that indicates the event in subsection (a), if the CCO does not challenge the adjusted RBC Report.

(c) If the CCO challenges an adjusted RBC Report, according to the terms of the CCO Contract, that indicates the event in subsection (a), notification by the Authority to the CCO that the Authority has, rejected the CCO's challenge.

(2) In the event of a Mandatory Control Level Event, the Authority shall take the following actions:

(a) Place the CCO under regulatory control and/or apply to have the CCO made the subject of court-ordered conservancy proceedings pursuant to Sections 24 through 37 of S.B. 1041.

(b) Terminate the CCO Contract(s) with the Authority and cause the Members covered by the CCO to be transferred to one or more other CCOs.

(3) Upon the occurrence of any of the following events, a CCO may appeal determination or action by the Authority in connection with any event described in this section pursuant to the terms of the CCO Contract. These events are as follows:

(a) Notification to a CCO by the Authority of an adjusted RBC Report;

(b) Notification to a CCO by the Authority that:

(A) The CCO's RBC Plan or revised RBC Plan is unsatisfactory; and

(B) Notification constitutes a Regulatory Action Level Event with respect to the CCO.

(c) Notification to a CCO by the Authority that the CCO has failed to adhere to its RBC Plan or revised RBC Plan and that the failure has a substantial adverse effect on the ability of the CCO to eliminate the Company Action Level Event with respect to the CCO in accordance with its RBC Plan or revised RBC Plan; or

(d) Notification to a CCO by the Authority of a Corrective Order with respect to the CCO.

(4) The Authority may keep confidential a CCO’s RBC Plan or the results or report of any examination or analysis conducted by the Authority in connection with a CCO’s RBC Plan if the Authority determines that disclosure of such information is not necessary to protect the public interest and may jeopardize the CCO’s ability to successfully implement the RBC Plan.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5225 REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Extraordinary Dividends and Other Distributions

(1) Requests for approval of extraordinary dividends or any other extraordinary distribution to shareholders shall include the following:

(a) The amount of the proposed dividend;

(b) The date established for payment of the dividend;

(c) A statement as to whether the dividend is to be in cash or other property and, if in property, a description thereof, its cost, and its fair market value together with an explanation of the basis for valuation;

(d) A copy of the calculations determining that the proposed dividend is extraordinary. The work paper must include the following information:

(A) The amounts, dates and form of payment of all dividends or distributions, including regular dividends but excluding distributions of the CCO’s own securities, paid within the period of twelve (12) consecutive months ending on the date fixed for payment of the proposed dividend for which approval is sought and commencing on the day after the same day of the same month in the last preceding year;

(B) Total capital and surplus as of the 31st day of December immediately preceding;

(C) Net income for the 12-month period ending the 31st day of December immediately preceding and the two preceding 12-months periods; and

(D) Dividends paid to stockholders excluding distributions of the CCO’s own securities in the preceding two calendar years.

(e) A balance sheet and statement of income for the period intervening from the last annual statement filed with the Authority and the end of the month preceding the month in which the request for dividend approval is submitted; and

(f) A brief statement as to the effect of the proposed dividend upon the CCO’s capital and surplus and the reasonableness of combined capital and surplus in relation to the CCO’s outstanding liabilities and the adequacy of surplus relative to the CCO’s financial needs.

(2) Each registered CCO shall report to the Authority all dividends and other distributions to shareholders within five business days following the declaration thereof, including the same information required by section (1)(d)(A) to (D) of this section.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5230 REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Acquisitions And Dispositions Of Assets, and Changes to Ceded Reinsurance Agreements; Assumption Reinsurance

(1) Every CCO shall file a report with the Authority disclosing material acquisitions and dispositions of assets or material nonrenewals, cancellations or revisions of ceded reinsurance agreements unless the subject transaction has been submitted to the Authority for review, approval or information under or pursuant to another provision of applicable law.

(2) The report required in subsection (1) is due no later than the 15th day following the end of the calendar month in which any of the reportable transaction occurred.

(3) A CCO shall not enter a transaction in which the CCO assumes or transfers obligations or risks on contracts under an Assumption Reinsurance Agreement or any equivalent agreement, unless the Authority first approves the transaction.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5235 REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Materiality and Reporting Standards for Asset Acquisitions and Dispositions

(1) No acquisitions or dispositions of assets need be reported pursuant to OAR 410-141-5230 if the acquisition or disposition is not material. For purposes of OAR 410-141-5230, a material acquisition (or the aggregate of any series of related acquisitions during any 30-day period) or disposition (or the aggregate of any series of related dispositions during any 30-day period) is one that is non-recurring and not in the ordinary course of business and involves more than five percent of the reporting CCO's total allowed assets as reported in its most recent statutory statement filed with the Authority.

(2) OAR 410-141-5230 applies to the following asset acquisitions and asset dispositions:

(a) Asset acquisitions include every purchase, lease, exchange, merger, consolidation, succession or other acquisition by or for the reporting CCO.

(b) Asset dispositions include every sale, lease, exchange, merger, consolidation, mortgage, hypothecation, assignment (whether for the benefit of creditors or otherwise), abandonment, destruction or other disposition.

(3) The following information is required to be disclosed in any report of a material acquisition or disposition of assets:

(a) Date of the transaction.

(b) Manner of acquisition or disposition.

(d) Nature and amount of the consideration given or received.

(e) Purpose of, or reason for, the transaction.

(f) Manner by which the amount of consideration was determined.

(g) Gain or loss recognized or realized as a result of the transaction.

(h) Name or names of the person or persons from whom the assets were acquired or to whom they were disposed.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5240 REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Materiality and Reporting Standards for Changes in Ceded Reinsurance Agreements

(1) No nonrenewals, cancellations or revisions of ceded reinsurance agreements need be reported pursuant to OAR 410-141-5230 if the nonrenewals, cancellations or revisions are not material. A material nonrenewal, cancellation or revision is one that affects:

(a) More than fifty percent of the CCO's total ceded capitated revenue;

(b) More than fifty percent of the CCO's total ceded indemnity and loss adjustment reserves; or

(c) More than fifty percent of the total reserve credit taken for business ceded, on an annualized basis, as indicated in the CCO's most recent annual statement.

(2) Either of the following events shall constitute a material revision that must be reported:

(a) An authorized reinsurer representing more than ten percent of a total cession is replaced by one or more unauthorized reinsurers.

(b) Previously established collateral requirements have been reduced or waived as respects one or more unauthorized reinsurers representing collectively more than ten percent of a total cession.

(3) No filing shall be required if the CCO's total ceded capitated revenue represents, on an annualized basis, less than ten percent of its total written capitated revenue for direct and assumed business.

(4) The following information is required to be disclosed in any report of a material nonrenewal, cancellation or revision of a ceded reinsurance agreement:

(a) Effective date of the nonrenewal, cancellation or revision;

(b) The description of the transaction with an identification of the initiator thereof;

(d) If applicable, the identity of the replacement reinsurers.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5245 EXAMINATIONS: CCO Production of Books and Records

(1) The Authority may require a CCO to produce books, records, accounts, papers, documents and computer and other recordings in the possession, custody or control of the CCO or the CCO’s affiliates that the Authority determines are needed for the Authority to investigate or examine the CCO’s financial condition or to investigate, examine or determine the CCO’s compliance with applicable Law, with the CCO Contract, and other agreements with the Authority.

(2) No person shall file or cause to be filed with the Authority any article, certificate, report, statement, application or any other information required or permitted to be so filed under Applicable Law or the CCO Contract and known to such person to be false or misleading in any material respect.

(3) If a CCO, without good cause, fails to comply with its obligations under subsections (1) or (2), the Authority may impose a civil penalty on the CCO pursuant to OAR 410-141-5380 and/or may suspend or revoke the CCO Contract, and other agreements with the Authority.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605 & ORS 415.101-415.430
Statutes/Other Implemented: ORS 414.570-414.686
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5250 EXAMINATIONS: Authority Examinations of CCOs

(1) The Authority shall examine every CCO, including an audit of the financial affairs of a CCO, as often as the Authority determines an examination to be necessary or otherwise appropriate under the circumstances. Without limiting the Authority’s right to examine a CCO at such times and with such frequency as the Authority determines to be necessary or otherwise appropriate under the circumstances, a CCO shall be examined not less than once (1) every five (5) years. An examination shall be conducted for such purposes and such scope as the Authority determines to be necessary or otherwise appropriate under the circumstances, including, without limitation, an investigation and examination of the financial condition of the CCO, its ability to fulfill its obligations and its manner of fulfillment, the nature of its operations and its compliance with these rules and applicable CCO Contract requirements.

(2) Examinations shall be conducted under and pursuant to the following practices and procedures, subject to such exceptions, modifications and other practices and procedures as the Authority determines to be necessary or otherwise appropriate under the circumstances:

(a) The Authority shall appoint one or more examiners to perform the examination and instruct them as to the scope of the examination. The Authority may contract and coordinate all or portions of the examination with DCBS. Any reference to the Authority in this section shall include DCBS when DCBS is working under an interagency agreement with the Authority to conduct the examination. DCBS is authorized to make recommendations to the Authority and to act in conjunction with the Authority in accordance with this section.

(b) The examiner(s) shall conduct the examination in accordance with the guidelines, practices, principles and procedures set forth in the Examiners Handbook adopted by the NAIC and identified by the Authority to be applicable for the examination. The Authority may instruct or allow the examiner(s) to follow or employ such other guidelines, practices, principles and procedures as the Authority determines to be necessary or otherwise appropriate under the circumstances.

(c) The Authority may retain appraisers, independent actuaries, independent certified public accountants and other professionals and specialists as needed. All costs associated with third parties engaged by the Authority is the financial responsibility of the CCO.

(d) The Authority, including its appointed examiners, may examine under oath all persons who may have material information regarding the property or business of the person being examined or investigated.

(3) Every person being examined or investigated shall produce all books, records, accounts, papers, documents and computer and other recordings in its possession or control, including, in the case of an examination, the property, assets, business and affairs of the person.

(4) Upon written request of the Authority or its examiners, the CCO, its affiliates and each officer, director, employee, contractor, agent or representative of the CCO and/or the CCO’s affiliates promptly shall produce to the Authority or its examiners, or otherwise shall promptly provide the Authority or its examiners with convenient, complete and free access to, all books, records, accounts, papers, documents and computer and other recordings in the possession, custody or control of such persons that relate in any way to the subject matter of the examination. The CCO shall use its best efforts to cause the CCO’s affiliates and each officer, director, employee, contractor, agent or representative of the CCO and/or the CCO’s affiliates to comply with a request made by the Authority or its examiners under this subsection 4.

(5) The procedure for completion of an examination shall be as follows:

(a) Not later than sixty days following completion the examination, the examiner(s) shall submit to the Authority a draft Report of Examination. The draft report shall include fact-findings and conclusions and also may include proposed recommendations for curative actions to be undertaken by the CCO based on the draft report’s fact-findings and conclusions.

(b) The Authority shall provide the CCO with a copy of the draft report and allow the CCO a reasonable opportunity to review and comment on the draft report. A copy of the draft report shall be delivered to the CCO by certified mail, addressed to the CCO’s home office or to such other point of contact as the CCO may designate in writing to the Authority for this purpose. The Authority shall consider the CCO’s comments on the draft report and may request additional information or meet with the CCO for the purpose of resolving questions or obtaining additional information. The Authority may consult with or cause the examiner(s) to consider any submissions made by the CCO in response to the draft report and any additional information provided to the Authority by the CCO.

(c) Before the Authority accepts and files the draft report as a final examination report available for publication or makes any matters relating thereto public, the CCO may request a contested case hearing on the draft report and any of its fact-findings, conclusions and recommendations. The CCO must request a hearing no later than twenty business days following the date on which the draft report was delivered to the CCO (“Hearing Request Period”).

(A) Contested case hearings shall be conducted pursuant to ORS 183.411 through ORS 183.497 and the Attorney General's Uniform and Model Rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 through OAR 137-003-0700, and the provisions of this rule.

(B) In a contested case conducted pursuant to this rule, an administrative law judge assigned by the Office of Administrative Hearings shall serve a proposed order incorporating the final examination report on all parties and the Authority, unless prior to the hearing the Authority notifies the administrative law judge that a final order may be served, within thirty (30) calendar days of the close of the evidentiary record in the contested case.

(C) The Authority shall issue a final order on the final examination report within thirty (30) days of receipt of the proposed order, which may adopt some or all of the proposed order, as the Authority shall determine in its sole discretion. The final order is effective immediately upon being signed or as otherwise provided in the order.

(D) The time limits established in rule may be waived or shortened by agreement among the parties and the Authority.

(E) All contested case hearing decisions are subject to judicial review under ORS 183.482 in the Court of Appeals.

(6) The Authority shall make a final examination report available for public inspection. If the Authority, in its sole discretion, considers that doing so is in the public interest, the Authority may publish notice of a final examination report, its availability for public inspection and/or a summary of, or excerpts from, the final examination report by such means (including print, broadcast and web-based media) as the Authority determines to be appropriate under the circumstances.

(7) OAR 410-141-5080 applies generally to examinations and the examination process under this section. In accordance with OAR 410-141-5080, the Authority may designate as confidential and exempt from public inspection any work papers, recorded information, documents and copies thereof that are produced or obtained by or disclosed to the examiner(s) or the Authority during the course of an examination (collectively, “Examination Materials”). If the Authority, in the Authority's sole discretion after notice to the CCO, determines that disclosure is necessary to protect the public interest, the Authority may make available any such Examination Materials to any other person in the course of the examination or to the public generally.

(8) Nothing in this section shall be construed or operate to limit the Authority’s right or obligation to disclose a draft report or final examination report, or any Examination Materials to any other federal or state regulatory authority where required by law, where permitted by the CCO’s agreement with the Authority, or where otherwise determined by the Authority to be in the public interest.

(9) No cause of action may arise, and no liability may be imposed against the Authority or DCBS, an authorized representative of the Authority or DCBS or any examiner appointed by the Authority or DCBS for any statements made or conduct performed in good faith pursuant to an examination or investigation. No cause of action may arise and no liability may be imposed against any person for communicating or delivering information or documents to the examiner(s) or the Authority or any authorized representative of the Authority in connection with an examination, or for providing testimony in the course of an examination, unless the person doing so acted in bad faith, with fraudulent intent or intent to deceive.

(10) Subsection (9) supplements, and does not abrogate or modify in any way, any common law or statutory privilege or immunity otherwise enjoyed by any person to which that subsection applies.

(11) Facts determined and conclusions made by the Authority pursuant to an examination shall be presumptive evidence of the relevant facts and conclusions in any judicial or administrative action.

(12) In addition to other powers of the Authority under these rules relating to the examination and investigation of CCOs, the Authority may order, at any time and from time to time, a CCO to produce such books, records, accounts, papers, documents and computer and other recordings in the possession of the CCO or its affiliates as are necessary to ascertain the financial condition of the CCO or to determine compliance with these rules. If the CCO fails to comply with such an order, the Authority may examine the affiliates to obtain such information, in addition to imposing sanctions or other remedies under these the Authority rules or the CCO Contract.

(13) At any time during the course of, or following, an examination, the Authority may take any other actions and exercise any other powers, remedies or authority available to the Authority or otherwise contemplated by these rules.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605 & 415.101-415.430
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 59-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5255 CCO ACQUISITIONS AND MERGERS: Purpose; Definitions

(1) The purpose of OAR 410-141-5255 to OAR 410-141-5280 is that of regulating the control or ownership of a CCO or of a CCO holding company system, in order to promote the public interest including the interests of CCO Members and stakeholders and to advance the goals and mission of the Authority and the Oregon Integrated and Coordinated Care Delivery System described in ORS 414.018 and ORS 414.570.

(2) The Authority shall adhere to the following guiding principles when reviewing proposed acquisitions:

(a) The health of Oregon Health Plan members and all Oregonians are at the center when analyzing potential impacts of proposed acquisitions;

(b) Health equity, access to care, health care quality, and costs are fundamental;

(c) The process shall be transparent, robust and informed by the public and stakeholders through meaningful engagement; and

(d) The Authority shall use resources wisely and collaborate with DCBS when applicable.

(3) Unless the context otherwise requires, as used in OAR 410-141-5255 to OAR 410-141-5280:

(a) “Acquiring party” means a person that acquires or attempts to acquire control of a CCO, that enters into an agreement to merge with or otherwise acquire control of a CCO as described in OAR 410-141-5260 or that engages in an activity described in OAR 410-141-5260, or an intermediary or subsidiary corporation that holds, directly or indirectly, the assets or voting securities or assumes the liabilities of a CCO or other entity;

(b) “Acquisition” means an agreement, arrangement or activity that results in a person acquiring control of another person, directly or indirectly, including but not limited to an acquisition of voting securities, a merger, an acquisition of assets or bulk reinsurance;

(d) “Health Equity” definition: Oregon shall have established a health system that creates health equity when all people can reach their full health potential and well-being and are not disadvantaged by their race, ethnicity, language, disability, age, gender, gender identity, sexual orientation, social class, intersections among these communities or identities, or other socially determined circumstances. Achieving health equity requires the ongoing collaboration of all regions and sectors of the state, including tribal governments to address:

(A) The equitable distribution or redistributing of resources and power; and

(B) Recognizing, reconciling and rectifying historical and contemporary injustices.

(e) “Significant portion” means, when acquired in one transaction or in a related or integrated series of transactions within any consecutive twelve-month period, ten percent or more of:

(A) The assets of the CCO; or

(B) The CCO’s in-force benefit contracts.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 38-2020, amend filed 08/05/2020, effective 08/07/2020
DMAP 3-2020, temporary amend filed 02/12/2020, effective 02/12/2020 through 08/09/2020
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5260 CCO ACQUISITIONS AND MERGERS: Activities Prohibited Unless Certain Provisions Satisfied

(1) Unless a person first satisfies the provisions of OAR 410-141-5265 to OAR 410-141-5280, the person may not engage in any of the following activities:

(a) A person other than the person that issues voting securities of a CCO may not acquire or attempt to acquire control of the CCO. For purposes of this paragraph, a person acquires or attempts to acquire control of a CCO if, as a result of engaging in and completing any of the following actions, in the open market or otherwise, the person would directly or indirectly control the CCO, or would control the CCO by exercising a right to acquire or by conversion:

(A) Making a tender offer for or a request or invitation for tenders of any voting security of the CCO;

(B) Entering into any agreement to exchange securities for any voting security of the CCO;

(D) Otherwise engaging in any activity that constitutes a change in control of a CCO requiring pre-approval from the Authority, as described in the CCO Contract.

(b) A person may not close or finalize an agreement to merge with or otherwise acquire control of a CCO.

(A) Acquiring, directly or indirectly, ownership of all or a significant portion of the assets of a CCO. For purposes of this subparagraph, such an acquisition includes an offer, a request or invitation for offers, an acquisition or series of acquisitions in the open market, an exchange offer or agreement, an agreement that provides an option to purchase, or a purchase of or offer to purchase securities that are convertible into voting securities.

(B) Bulk reinsurance by one CCO of all or a significant portion of the Members, or a major class of the Members, who are covered by another CCO or related or affiliated group of CCOs. The provisions of this subparagraph do not apply to ordinary or customary reinsurance, or reinsurance pursuant to a treaty or treaties approved by the Authority.

(C) Any other arrangement that brings together under common ownership, control or responsibility all or a significant portion of the assets, liabilities or CCO Contract in force of two or more persons, at least one of which is a CCO.

(2) The provisions of subsection (1) of this section do not apply to any offer, request, invitation, agreement or acquisition the Authority exempts by order as:

(a) Not having been made or entered into for the purpose and not having the effect of changing or influencing the control or ownership of a CCO; or

(b) Otherwise not comprehended within the purposes of subsection (1) of this section.

(3) A person that seeks in any manner to give up a controlling interest in a CCO shall file a confidential notice of the person’s proposed divestiture with the Authority and send a copy of the notice to the CCO at least 30 days before the person ceases to own or hold a controlling interest in the CCO. The notice is confidential until the transaction that transfers control of the CCO concludes, unless the Authority determines, in the Authority’s sole discretion, that keeping the notice confidential will interfere with the enforcement of this subsection.

(a) The Authority shall determine in which instances an acquisition or divestiture of control will require a person to file for and obtain approval of the transaction;

(b) This subsection does not apply if a person files a statement under OAR 410-141-5350.

(4) If an acquisition is otherwise subject to this section, the acquiring party shall file a notice with the Authority in accordance with OAR 410-141-5265. An acquiring party that does not file the notice may be subject to the penalty specified in OAR 410-141-5380.

(5) The Authority shall treat a notice and information that a person submits in accordance with this section, as well as any information that the person submits in accordance with OAR 410-141-5265 or 410-141-5270, as confidential and exempt from disclosure under ORS 192.311 to 192.478, to the extent the Authority determines that such information is trade secret, as defined in ORS 192.345, including compensation paid to providers by a CCO.

(6) The Authority shall treat a notice and information that a person submits in connection with a transaction that is subject to review by either the Health Care Market Oversight Program or DCBS in accordance with the provisions of OAR 410-141-5278.(7) In addition to satisfying the requirements of OAR 410-141-5265 to OAR 410-141-5280, a material change transaction (as defined in OAR 409-070-0005) involving a CCO must satisfy the requirements of OAR 409-070-0000 to OAR 409-070-0085.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 71-2022, amend filed 08/22/2022, effective 08/22/2022
DMAP 6-2022, temporary amend filed 02/03/2022, effective 03/01/2022 through 08/27/2022
DMAP 38-2020, amend filed 08/05/2020, effective 08/07/2020
DMAP 3-2020, temporary amend filed 02/12/2020, effective 02/12/2020 through 08/09/2020
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5265 CCO ACQUISITIONS AND MERGERS: Procedure For Acquiring Controlling Interest

(1) An acquiring party shall:

(a) File a complete Form A, as described in OAR 410-141-5270, with the Authority for approval. If more than one acquiring party is required to file a Form A under this paragraph, any or all acquiring parties that are acting in concert may jointly file a Form A;

(b) Deliver or mail a statement, as described in (4) below, to the Authority concurrently with a complete Form A, as described in (a) above. this statement is required to be sent by certified mail, return receipt requested. If a joint statement is filed under paragraph (a) of this subsection, the joint statement must be mailed or delivered under this paragraph.

(2) If the person being acquired is considered to be a CCO solely because of the definition of “CCO” in OAR 410-141-5255, the name of the CCO on the cover page shall be indicated as follows: “ABC Company, a subsidiary of XYZ Holding Company.”

(3) References to “the CCO” contained in Form A shall refer to both the subsidiary CCO and the person being acquired.

(4) The statement an acquiring party is required to file with the Authority under this (1)(b) above must be made under oath or affirmation and contain the following information:

(a) The name and address of the CCO that is subject to the acquisition and of each acquiring party that must file the statement, additional biographical and business information about each acquiring party that must file the statement, and business plans and information regarding persons who shall serve as or perform functions of directors or officers, as required by the Authority.

(b) The source, nature and amount of the consideration used or to be used in effecting the activity, a description of any transaction in which funds were or are to be obtained for the activity and the identity of persons that provide the consideration. If a source of consideration is a loan made in the lender’s ordinary course of business, the identity of the lender must remain confidential if the acquiring party filing the statement requests confidentiality.

(c) Fully audited financial information as to the earnings and financial condition of each acquiring party for the acquiring party’s preceding five fiscal years, or for as long as the acquiring party and any predecessors of the acquiring party have existed, if the acquiring party and the acquiring party’s predecessors have existed for a shorter period of time, and similar unaudited information as of a date not earlier than 90 days before the statement was filed.

(d) Any plan or proposals that each acquiring party that must file a statement has to liquidate the CCO, to sell the CCO’s assets or to merge or consolidate the CCO with any person or to make any other material change in the CCO’s business, corporate structure or management.

(e) The number of shares of any security of a type described in OAR 410-141-5260 that each acquiring party proposes to acquire, the terms of any offer, request, invitation, agreement or acquisition of any security of a type described in OAR 410-141-5260 and a statement as to the method by which the acquiring party determined the fairness of the proposal.

(f) The amount of each class of any security of a type described in OAR 410-141-5260 that each acquiring party owns beneficially or concerning which each acquiring party has a right to acquire beneficial ownership.

(g) A full description of any contracts, agreements or understandings with respect to any security of a type described in OAR 410-141-5260 in which any acquiring party is involved, including but not limited to contracts, agreements or understandings that govern a transfer of any of the securities or that relate to joint ventures, loan or option arrangements, puts or calls, loan guarantees, guarantees against loss or guarantees of profits, division of losses or profits, or giving or withholding proxies. The description must identify the persons with which each acquiring party has entered into the contract, agreement or understanding.

(h) The names of persons who have purchased any securities of a type described in OAR 410-141-5260 during the 12 months before the date on which the acquiring party files the statement under this section, together with the dates of purchase and the amount and type of consideration the persons paid or agreed to pay.

(i) A description of any recommendations to purchase any securities of a type described in OAR 410-141-5260 that an acquiring party made during the twelve (12) months before the date on which the acquiring party files the statement under this section, or of any recommendations that another person made as a result of interviewing an acquiring party or at an acquiring party’s suggestion.

(j) Copies of all tender offers, requests, exchange offers, invitations to tender or agreements to acquire securities of a type described in OAR 410-141-5260, along with any additional material used to solicit the tender offers, requests, exchange offers, invitations to tender or agreements, if any additional material was distributed.

(k) The term of any contract, agreement or understanding for soliciting securities of a type described in OAR 410-141-5260 for tender that is made with or proposed to be made with a broker-dealer, together with the fees, commissions or other compensation the broker-dealer will receive in connection with the solicitation.

(L) Business plans for the CCO after the proposed activity, including analyses of the following (with any relevant supporting documentation):

(A) How, after the proposed activity, the CCO shall be able to:

(i) Innovate, coordinate care, provide value, and deliver high-quality services;

(ii) Demonstrate commitment to addressing health disparities and inequities;

(iii) Be strongly connected to the community served by the CCO, including the CCO’s community advisory council, community health improvement plan, and the Authority’s requirements to engage with the community;

(iv) Provide services cost effectively and within cost growth limits imposed by the Authority or the state;

(v) Support social determinants of health in the community served by the CCO, as required by its CCO Contract;

(vi) Perform its responsibilities under the CCO Contract and applicable law;

(vii) Comply with requirements in the CCO Contract and applicable law concerning its governing body; and

(viii) Satisfy the policy priorities adopted by the Oregon Health Policy Board.

(B) If the proposed activity may result in the termination of members from a CCO or the transition of members from one CCO to another CCO, how the acquiring entity and CCO shall facilitate those terminations and transitions in compliance with 42 C.F.R. §§ 438.52, 438.56, 438.62 and the CCO Contract.

(D) Health equity in Oregon, including data on race, ethnicity, preferred spoken and written languages and disability status (collected in accordance with the practices and standards established in OAR chapter 943, division 70) of patient populations impacted by the proposed activity;

(E) The financial stability of the CCO and the financial strategies that may influence the CCO; and

(F) The CCO’s medical loss ratio.

(m) An agreement to submit an annual enterprise risk report under OAR 410-141-5330 during which the acquiring party controls the CCO and an acknowledgment that the acquiring party and all subsidiaries in the holding company system that are within the acquiring party’s control will provide, at the director’s request, information the director needs to evaluate enterprise risk to the CCO.

(5) All requests or invitations for tenders or advertisements that make a tender offer or request or invite tenders of securities for control of a CCO made by or on behalf of any acquiring party required to file Form A under this section must have the information specified in subsection (2) of this rule. Copies of the materials must be filed with the Authority at least ten (10) days before the time the materials are first published or sent or given to security holders. Any additional materials that solicit or request the tenders after the initial solicitation or request must have the information specified in subsection (2) of this rule. Copies of the additional materials must be filed with the Authority at least ten (10) days prior to the time the materials are first published or sent or given to security holders.

(6) If any acquiring party required to file Form A under this section is a partnership, limited partnership, syndicate or other group, the Authority may require that the information specified in subsection (2) of this rule be given with respect to each partner of the partnership or limited partnership, each member of the syndicate or group and each person that controls the partner or member. If any partner, member or person is a corporation or if the acquiring party is a corporation, the Authority may require that the information described in subsection (2) of this rule be given with respect to the corporation and each officer and Authority of the corporation and each person that is directly or indirectly the beneficial owner of more than 10 percent of the outstanding securities of the corporation.

(7) If any material change occurs in the facts set forth in the statement filed under this section, the party that filed the statement shall file with the Authority and send to the CCO, within two business days after the party learns of the change, an amendment that sets forth the change together with copies of all documents and other material relevant to the change.

(8) If an offer, request, invitation, agreement or acquisition described in OAR 410-141-5260 is proposed to be made by means of a registration statement under the Securities Act of 1933, 15 U.S.C.A. §77a et seq., or in circumstances that require disclosing similar information under the Securities Exchange Act of 1934, 15 U.S.C.A. § 78a et seq., or under a state law that requires a similar registration or disclosure, the party or parties may use the registration statement or disclosure to provide the information the party or parties must provide in the statement required under subsection (1) of this section. Such a registration statement may be used to supply information required by a Form A, not to replace the Form A.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 38-2020, amend filed 08/05/2020, effective 08/07/2020
DMAP 3-2020, temporary amend filed 02/12/2020, effective 02/12/2020 through 08/09/2020
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5270 CCO ACQUISITIONS AND MERGERS: Information to Be Included in Form A

When Form A is required to be filed with the Authority pursuant to OAR 410-141-5265, the Form A shall include the following information:

(1) If any acquiring party required to file Form A is an individual, the individual shall identify their principal occupation and all offices and positions held during the past five years, and list any arrests, charges, and conviction of crimes other than minor traffic violations during the past 10 years,

(2) If any acquiring party required to file Form A is not an individual, a report of the nature of its business operations during the past five years or for such lesser period as the acquiring party and any predecessors of the acquiring party have been in existence, an informative description of the business intended to be done by the acquiring party and its subsidiaries, and a list of all individuals who are or who have been selected to become directors or executive officers of the acquiring party or who perform or shall perform functions appropriate to the positions. The list shall include for each individual the information required by subsection (1).

(3) For each acquiring party required to file a Form A, the number of shares of any security that each acquiring party proposes to acquire in connection with the acquisition, the terms of any proposed offer or agreement relating to the acquisition and a statement as to the method by which the fairness of the proposal was determined.

(4) The amount of each class of any security of the type to be acquired in connection with the acquisition that is beneficially owned or concerning which there is a right to acquire beneficial ownership by any acquiring party.

(5) For each acquiring party required to file a Form A, a full description of any contracts, arrangements or understandings with respect to any security of the type to be acquired in connection with the acquisition in which such acquiring party is involved with, including, without limitation, those involving transfer of any of the securities, joint ventures, loan or option arrangements, puts or calls, guarantees of loans, guarantees against loss or guarantees of profits, division of losses or profits or the giving or withholding of proxies. The description shall identify the persons with whom the contracts, arrangements or understandings have been entered.

(6) A description of the purchase of any security of the type to be acquired in connection with the acquisition during the 12 calendar months preceding the filing of the statement, by any acquiring party required to file Form A, including the dates of purchase, names of the purchasers and consideration paid or agreed to be paid for the security.

(7) A description of any recommendation to purchase any security of the type to be acquired in connection with the acquisition made by any acquiring party required to file Form A, or by anyone based upon interviews or at the suggestion of any acquiring party required to file Form A, during the 12 calendar months preceding the filing of the statement.

(8) Copies of all tender offers for, requests or invitations for tenders of, exchange offers for and agreements to acquire or exchange any securities of the type to be acquired in connection with the acquisition and, if distributed, copies of additional soliciting material relating thereto.

(9) A description of the terms of any agreement, contract or understanding made with or proposed to be made with any broker-dealer as to solicitation for tender of securities of the type to be acquired in connection with the acquisition, including the amount of any fees, commissions or other compensation to be paid to any broker-dealer in connection with the agreement, contract or understanding.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5275 CCO ACQUISITIONS AND MERGERS: Hearing, Request, Notice

(1) Contested case hearings shall be conducted pursuant to ORS 183.411 through ORS 183.497 and the Attorney General's Uniform and Model Rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 through OAR 137-003-0700, and the provisions of this rule.

(2) A party to a CCO Form A application that wishes to contest a Notice of Proposed Final Order issued by the Authority that fully resolves the Form A application must request a hearing within fifteen (15) calendar days from the date of service of the final order and a notice of right to a hearing.

(3) A contested case hearing must be held within thirty (30) business days after the date the written request for a hearing was filed.

(4) In addition to any other notice required under ORS Chapter 183, at least twenty (20) business days before the hearing, the Director shall notify the parties to the CCO Form A application that requested a hearing of the hearing.

(5) The issues to be considered in a contested case conducted pursuant to this rule shall be limited in scope to the facts and conclusions contained in the final order or determination.

(6) In a contested case conducted pursuant to this rule, an administrative law judge assigned by the Office of Administrative Hearings shall serve a proposed order on all parties and the Authority, unless prior to the hearing the Authority notifies the administrative law judge that a final order may be served, within thirty (30) calendar days of the close of the evidentiary record in the contested case.

(7) The Authority shall issue a final order within thirty (30) days of receipt of the proposed order, which may adopt some or all of the proposed order, as the Authority shall determine in its sole discretion. The final order is effective immediately upon being signed or as otherwise provided in the order.

(8) The time limits established in rule may be waived or shortened by agreement among the parties and the Authority.

(9) All contested case hearing decisions are subject to judicial review under ORS 183.482 in the Court of Appeals.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5278 CCO ACQUISITIONS AND MERGERS: Confidentiality

(1) The Authority shall maintain all information and materials filed by an applicant in connection with a material change transaction under review by the Health Care Market Oversight Program pursuant to the confidentiality requirements of ORS 415.501(13) and OAR 409-070-0070.

(2) Confidential materials filed by an applicant in connection with a transaction that is subject to review by each of the Authority and the Department shall be maintained as confidential materials in accordance with ORS 705.137.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, adopt filed 12/29/2024, effective 01/01/2025

Or. Admin. R. 410-141-5280 CCO ACQUISITIONS AND MERGERS: Determination Concerning Proposed Activity, Time For Decision, Grounds For Refusal

(1) Prior to approving or disapproving the proposed activity, the Authority shall engage the public, Oregon's Medicaid Advisory Committee, and the Community Advisory Councils of the CCO. The Authority’s engagement of the public shall include the following, coordinated with DCBS where efficient:

(a) Seeking recommendations by the Community Advisory Councils of the CCO regarding persons who should be notified;

(b) A public listening session in each service area of the CCO;

(d) An opportunity to provide input on a draft of the Authority’s detailed analyses described under subsection (4);

(e) Seeking feedback from the Medicaid Advisory Committee; and

(f) Posting on the Authority’s web site of the Form A and supporting documentation relating to the Form A. If any such document contains information protected from disclosure by OAR 410-141-5278, state or federal law or protected from disclosure as a trade secret, as defined in ORS 192.345, including compensation paid to providers by the CCO, then the Authority shall redact the document pursuant to ORS 192.338.

(2) The effective date of the activity shall not be allowable until 60 days after the Authority has rendered a determination concerning the proposed activity described in OAR 410-141-5260.. The Authority may refuse, after a contested case hearing, to approve a proposed activity if:

(a) The activity is contrary to law or would result in a prohibited combination of risks or classes of insurance;

(b) The activity is inequitable or unfair to the Members or shareholders of any CCO involved in, or to any other person affected by, the proposed activity. However, in connection with an acquisition of the CCO’s voting securities from the CCO’s shareholders, the Authority shall evaluate whether the proposed acquisition is fair to the shareholders of the CCO to be acquired only with respect to any shareholders that are unaffiliated with the acquiring party or parties and that would remain after the acquisition is completed;

(A) The security of and service to be rendered to Members of any CCO involved in the proposed activity or would otherwise prejudice the interests of such Members or other Oregonians;

(B) Access to and quality of health care for Oregonians, or would substantially increase the cost of health care for Oregonians, including health care outside of the Medicaid program; or

(i) Perform its obligations described in the CCO Contract;

(ii) Innovate, coordinate care, provide value, and deliver high-quality services;

(iii) Demonstrate commitment to addressing health disparities and inequities;

(iv) Be strongly connected to the community served by the CCO, including the CCO’s community advisory council, community health improvement plan, and the Authority requirements to engage with the community;

(v) Provide services cost effectively and within cost growth limits imposed by the Authority or the state;

(vi) Support social determinants of health in the community served by the CCO, as required by its CCO Contract; or

(vii) Satisfy the Authority’s policy priorities as required by its CCO Contract or as adopted by the Oregon Health Policy Board.

(d) The activity provides for a foreign or alien CCO to be an acquiring party, and the Authority further finds that the CCO cannot satisfy the requirements of this state for transacting the CCO business that would be affected by the activity;

(e) The activity or the completion of the activity would substantially diminish competition in this state or tend to create a monopoly. An activity that the Authority determines would substantially diminish competition in this state or tend to create a monopoly may be approved if within a specific period of time a party removes the basis upon which the Authority would have otherwise disapproved the activity;

(f) After the change of control or ownership, the CCO to which the activity described in OAR 410-141-5260 applies would not be able to satisfy the requirements for receiving a CCO Contract to transact the line or lines of business for which the CCO is currently authorized;

(g) The financial condition of any acquiring party might jeopardize the financial stability of the CCO;

(h) The plans or proposals that the acquiring party has to liquidate the CCO, sell the CCO’s assets or consolidate or merge the CCO with any person, or to make any other material change in the CCO’s business or corporate structure or management, are unfair and unreasonable to the CCO’s Members and not in the public interest;

(i) The competence, experience and integrity of the persons that would control the operation of the CCO are such that permitting the activity or permitting completion of the activity would not be in the interest of the CCO’s Members and the public;

(j) Any CCO involved in the activity or any acquiring party does not comply with, or the activity presents a substantial risk that any such CCO or acquiring party will not comply with:

(A) ORS 414.572(2), with respect to the CCO’s governing body;

(B) 42 C.F.R. Part 438, Subpart H or 42 C.F.R. 438.808, with respect to the CCO’s ownership, control and affiliations;

(D) Any other applicable law; or

(E) The obligations described in the CCO Contract.

(k) The activity or completing the activity is likely to be hazardous or prejudicial to members of the CCO, other Medicaid members, or the insurance-buying public;

(L) The activity or completing the activity is likely to reduce the CCO’s demonstrated commitment to addressing health disparities and inequities, create or increase disparities or inequities, or make it more difficult to achieve health equity in the state;

(m) The activity is subject to other material and reasonable objections.

(3) If the Authority does not approve the activity, then the activity may not proceed, without regard to whether DCBS has approved it. If the activity is subject to approval by DCBS, then:

(a) The Authority shall work in concert with DCBS to jointly analyze the proposed acquisition;

(b) The Authority may rely on DCBS as to grounds that are common to the DCBS approval and the Authority approval;

(c) The Authority shall exercise independent judgment as to grounds for the Authority’s approval that are not grounds for DCBS approval; and

(d) The Authority shall approve the activity only if DCBS also approves the activity and shall do so concurrently.

(4) The Authority may disapprove, approve, or approve with conditions a proposed acquisition. OHA shall publish detailed analyses justifying OHA’s decisions. If the Authority disapproves the proposed activity, the Authority shall promptly notify, in writing, the CCO and each acquiring party involved in the proposed activity, specifying the bases, factors and reasons for the disapproval and giving the CCO and each acquiring party that filed the statement relating to the proposed activity an opportunity to amend the statement, if possible, to obviate the Authority’s objections.

(5) If the Authority determines that a party that proposes to acquire control of a CCO must maintain or restore the CCO’s capital to a level required under the laws and rules of this state, the Authority shall make and communicate the determination to the acquiring party not later than 60 days after the acquiring party files the statement required under OAR 410-141-5265.

(6) The acquiring party or parties that filed Form A under OAR 410-141-5265 shall file any amendment to Form A that responds to the Authority’s disapproval and, if a contested case hearing was held on the proposed activity pursuant to OAR 410-141-5275, shall resubmit the amendment to the Authority no later than 30 days following the date of the Authority’s order.

(7) The Authority may retain at the acquiring party’s expense any actuaries, accountants and other experts not otherwise a part of the Authority’s staff as the Authority may reasonably need to assist the Authority in reviewing the proposed activity.

(8) The Authority may establish the effective date of an activity to which OAR 410-141-5260 applies in the order that approves the activity.

(9) If the Authority issues a notice of approval, the acquiring party and the CCO must submit to the Authority the disclosures required by 42 C.F.R. § 455.104.

(10) Not later than the 30th day after consummation of an activity described in OAR 410-141-5260, the acquiring party shall submit to the Authority a statement that the activity has been consummated. The statement must be made under the oath of the presiding officer of the board of directors of the acquiring party.

(11) Not later than one year after consummation of an activity described in OAR 410-141-5260, the CCO subject to the acquisition shall submit to the Authority a retrospective review of the transaction. The retrospective review shall include analyses of the following (with any relevant supporting documentation, and with specific regard to each of the paragraphs of OAR 410-141-5265(5)(L)):

(a) The extent to which the business plans for the CCO after the proposed activity, as submitted to the Authority in response to OAR 410-141-5265(5)(L), have been realized; and

(b) The explanation for, and the CCO’s planned rectification of, any respect in which those business plans have not been realized.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 39-2020, minor correction filed 08/07/2020, effective 08/07/2020
DMAP 38-2020, amend filed 08/05/2020, effective 08/07/2020
DMAP 3-2020, temporary amend filed 02/12/2020, effective 02/12/2020 through 08/09/2020
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5283 CCO ACQUISITIONS AND MERGERS: Compliance with Conditions

(1) Following approval of a Form A, the Authority may verify compliance with any conditions that the Authority included in its approval of the transaction and issue such additional orders, following notice and opportunity for hearing, as may be necessary to enforce compliance with the terms and conditions of the approval of the transaction; provided however, that the Authority may not impose new conditions that are unrelated to, or not reasonably required to enforce compliance with, those conditions, if any, that were included in the Authority's approval of the transaction.

(2) No person shall file or cause to be filed with the Authority or the Department any notice, article, certificate, report, statement, application or any other information required or permitted to be so filed and known to such person to be false or misleading in any material respect.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, adopt filed 12/29/2024, effective 01/01/2025

Or. Admin. R. 410-141-5285 CCO HOLDING COMPANY REGULATION: Definitions

Unless the context otherwise requires, as used in OAR 410-141-5225 to OAR 410-141-5355:

(1) “Affiliate” means a person that directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with, another person.

(2) “CCO holding company system” means two or more affiliated persons, one or more of which is a CCO, and includes a financial holding company as described in section 103 of the federal Gramm-Leach-Bliley Act (P.L. 106-102).

(3) “CCO subject to registration” means a CCO that is subject to the holding company registration requirements of OAR 410-141-5290.

(4) “Control” means possessing the direct or indirect power to direct or cause the direction of the management and policies of a person whether by owning voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position or corporate office the person holds.

(5) “Enterprise risk” means an activity, circumstance, event or series of events that involve one or more of a CCO’s affiliates and that, if not remedied promptly, are likely to have an adverse material effect on the CCO’s or the CCO holding company system’s financial condition or liquidity, including but not limited to an activity, circumstance, event or series of events that would cause the CCO’s risk-based capital to fall into company action level or cause the Authority to determine that the CCO is in hazardous financial condition.

(6) “Executive officer” means chief executive officer, chief operating officer, chief financial officer, treasurer, secretary, controller and any other individual performing functions corresponding to those performed by the foregoing officers under whatever title.

(7) “Form A” means the form prescribed by OAR 410-141-5270.

(8) “Form B” means the form prescribed by OAR 410-141-5300.

(9) “Form C” means the form prescribed by OAR 410-141-5300.

(10) “Form D” means the form prescribed by OAR 410-141-5320.

(11) “Form F” means the form prescribed by OAR 410-141-5330.

(12) “Group capital calculation” means a calculation made in accordance with instructions that the National Association of Insurance Commissioners publishes for the purpose of specifying the method of calculation. The director of the Department of Consumer and Business Services shall prescribe, on a periodic basis, the instructions published by the National Association of Insurance Commissioners. The director of the Department of Consumer and Business Services decision to prescribe the instructions for the method of calculation shall be posted on the Department of Consumer and Business Services' Division of Financial Regulation website at dfr.oregon.gov.

(13) “Person” means an individual, corporation, political subdivision, limited liability company, partnership, association, joint stock company, trust or unincorporated organization, or an entity or combination of entities similar to the entities described in this paragraph. “Person” does not include:

(a) A joint venture partnership that is engaged exclusively in owning, managing, leasing or developing real or tangible personal property; or

(b) For the purposes of OAR 410-141-5000 through 410-141-5355, a securities broker that holds, in the usual and customary broker’s function, less than 20 percent of the voting securities of a CCO or of any person that controls.

(14) “Political subdivision” has the meaning prescribed by OAR 410-141-5000.

(15) “Security holder” means a person that owns a security of another person, including a security denominated as common stock, preferred stock, membership, or a debt obligation and any instrument that is convertible into or that is evidence of the right to acquire the security of another person.

(16) “Subsidiary” means an affiliate that is controlled by a person directly or indirectly through one or more intermediaries.

(17) “Ultimate controlling person” means a person that is not controlled by any other person. A CCO holding company system may have more than one ultimate controlling person.

(18) “Voting security” means a security that entitles the owner or holder of the security to vote at a meeting of shareholders or members, including a security that is convertible into a voting security or that is evidence of a right to acquire a voting security.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5290 CCO HOLDING COMPANY REGULATION: Members of Holding Company Systems; Registration Requirements

(1) Every CCO that is a member of a CCO holding company system shall register with the Authority as provided in this section.

(2) A CCO that is subject to registration under this section shall register not later than 15 days after the date the CCO becomes subject to registration, and annually thereafter on or before April 30 for the previous calendar year, unless the Authority for good cause shown extends the time for registration, and then within such extended time.

(3) The Authority may require or allow two or more affiliated CCOs subject to registration requirements under this section to file a consolidated registration statement.

(4) The registration requirements of OAR 410-141-5290 to OAR 410-141-5355 do not apply to any CCO, information or transaction the Authority exempts by rule or order.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5295 CCO HOLDING COMPANY REGULATION: Form and Contents of Registration Statement

(1) Every CCO that is subject to the registration requirements of OAR 410-141-5290 shall file with the Authority a completed Form B.

(2) Form B, must list, describe, summarize or include, as appropriate:

(a) The capital structure, general financial condition, ownership and management of the CCO and any person that controls the CCO;

(b) The identity and relationship of every member of the CCO holding company system;

(c) The following agreements in force and transactions currently outstanding or that have occurred during the last calendar year between the CCO and the CCO’s affiliates:

(A) Loans, other investments, or purchases, sales or exchanges of securities of the affiliates by the CCO or of the CCO by the CCO’s affiliates;

(B) Purchases, sales or exchanges of assets;

(D) Guarantees or undertakings for the benefit of an affiliate that result in an actual contingent exposure of the CCO’s assets to liability;

(E) All management agreements, service contracts and all cost-sharing arrangements;

(F) Reinsurance agreements;

(G) Dividends and other distributions to shareholders;

(H) Consolidated tax allocation agreements; and

(I) Any pledge of the CCO’s stock, including stock of any subsidiary or controlling affiliate, for a loan made to any member of the CCO holding company system.

(d) Financial statements of or within a CCO holding company system, including financial statements of affiliates, if the Authority requests the financial statements:

(A) Financial statements that are subject to this paragraph include, but are not limited to, annual audited financial statements that the CCO or the CCO holding company system files with the United States Securities and Exchange Commission under Securities Act of 1933, 15 U.S.C.A. §77a et seq., or the Securities Exchange Act of 1934, 15 U.S.C.A. § 78a et seq;

(B) A CCO that must file financial statements under this paragraph may satisfy the requirement by providing the Authority with the parent corporation financial statements that have been filed most recently with the United States Securities and Exchange Commission.

(e) Other matters concerning transactions between registered CCOs and any affiliates as may be included from time to time in any registration forms prescribed by the Authority;

(f) Affidavits that state that:

(A) The CCO’s Board is responsible for and oversees corporate governance and internal controls; and

(B) The CCO’s officers or senior management have approved and implemented, and continue to maintain and monitor, corporate governance and internal control procedures.

(g) Each Form B must have a summary that outlines all items in the current Form B or Authority approved NAIC prescribed registration statement that have changed from the previously filed Form B or registration statement.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5300 CCO HOLDING COMPANY REGULATION: Registration Statement Filing

(1) A CCO required to file an annual registration statement pursuant to OAR 410-141-5290 shall:

(a) Furnish the required information on Form B. Form B is set forth on the website of the Authority at https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(b) Include a statement that the CCO’s Board oversees corporate governance and internal controls.

(2) The Authority may allow a CCO that is part of a CCO holding company system to register on behalf of an affiliated CCO that is required to register under OAR 410-141-5290 and to file all information and material required to be filed under the registration requirements of OAR 410-141-5285 to OAR 410-141-5355.

(3) A CCO required to file an annual registration statement pursuant to OAR 410-141-5290 is also required to furnish information required on Form C. Form C is set forth on the website of the Authority at https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(4) The Authority may allow an authorized CCO that is part of a CCO holding company system to register on behalf of an affiliated CCO that is required to register under OAR 410-141-5290 and to file all information and material required to be filed under the registration requirements of OAR 410-141-5290 to OAR 410-141-5355.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.605 & 414.591
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5305 CCO HOLDING COMPANY REGULATION: Information Required to Be Disclosed

(1) Unless the Authority by rule or order provides otherwise, sales, purchases, exchanges, loans or extensions of credit, investments or guarantees involving one-half of one percent or less of a CCO’s admitted assets as of the December 31 immediately preceding the date of the registration statement or amendment shall not be deemed material for purposes of registration under OAR 410-141-5290 to OAR 410-141-5380.

(2) Information that is not deemed material under subsection (1) for the purposes of registration under OAR 410-141-5285 to OAR 410-141-5380 need not be disclosed on the registration statement filed pursuant to OAR 410-141-5355.

(3) Any person within a CCO holding company system subject to registration shall provide complete and accurate information to a CCO when such information is necessary to enable the CCO to comply with the registration requirements of OAR 410-141-5285 to OAR 410-141-5355.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5310 CCO HOLDING COMPANY REGULATION: Presumption of Control; Rebuttal

(1) The Authority shall presume that a person controls another person if the person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing, 10 percent or more of the voting securities of the other person.

(2) A person may rebut this presumption by filing a disclaimer of affiliation in the manner provided under OAR 410-141-5315.

(3) The Authority may determine that control exists in fact, notwithstanding the absence of a presumption that control exists in fact.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5315 CCO HOLDING COMPANY REGULATION: Disclaimer of Affiliation

(1) Any person, CCO or member of a CCO holding company system may file with the Authority a disclaimer of affiliation with any authorized CCO. The disclaimer must contain the following information:

(a) The number of authorized, issued and outstanding voting securities of the subject;

(b) With respect to the person whose control is denied and all affiliates of such person, the number and percentage of shares of the subject’s voting securities which are held of record or known to be beneficially owned, and the number of shares concerning which there is a right to acquire, directly or indirectly.

(2) All material relationships and bases for affiliation between the subject and the person whose control is denied and all affiliates of such person.

(3) A disclaimer that the person, CCO or member of the CCO holding company system files under this section is effective unless within 30 days after the Authority receives a complete disclaimer the Authority notifies the person, the CCO or the member of the CCO holding company system that Authority has disallowed the disclaimer, unless tolled by agreement between the Authority and the disclaiming party.

(4) The Authority shall hold a contested case hearing upon written request for a hearing by the person, CCO or member of a CCO holding company system that filed the disclaimer. Such request must be filed within 15 business days from the date the Authority provides written notice it has disallowed the disclaimer. The provisions of ORS Chapter 183 govern the hearing procedures and any judicial review of a final order issued in a contested case hearing.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5318 CCO Holding Company Regulation: Group Capital Calculation

An insurance holding company system subject to the group capital calculation defined in Chapter 836 that includes a CCO, must include their CCO in their group capital calculation.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 94-2025, adopt filed 12/22/2025, effective 01/01/2026

Or. Admin. R. 410-141-5320 CCO HOLDING COMPANY REGULATION: Transactions Within Holding Company

(1) A transaction within a CCO holding company system, to which a CCO subject to registration is a party, is subject to the following standards:

(a) The terms must be fair and reasonable.

(b) Charges or fees for services performed must be reasonable.

(c) Expenses incurred and payment received must be allocated to the CCO in conformity with customary insurance accounting practices that are consistently applied.

(d) The books, accounts and records of each party to the transaction must be maintained so as to disclose clearly and accurately the nature and details of the transaction, including accounting information that is necessary to support the reasonableness of the charges or fees to the respective parties.

(e) The combined capital and surplus of the CCO following any transaction with an affiliate or any shareholder dividend must be reasonable in relation to the CCO’s outstanding liabilities and adequate to the CCO’s financial needs.

(2) The Authority may prescribe from time to time required provisions that must be included in agreements with affiliates for cost-sharing services and management.

(3) A CCO and any person in the CCO’s CCO holding company system may enter into a transaction described in subsection (4), including an amendment to or modification of an affiliate agreement that is subject to standards set forth in this section, only if:

(a) The CCO has notified the Authority of the CCO’s intention to enter into the transaction in writing and not later than the 30th day before the transaction, or within a shorter period the Authority allows; and

(b) The Authority does not disapprove the transaction within the period.

(4) Subsection (3) applies to the following transactions:

(a) Sales, purchases, exchanges, loans or extensions of credit, guarantees or investments, if the transactions equal or exceed the lesser of three percent of the CCO’s allowed assets or 25 percent of the CCO’s combined capital and surplus, each as of the 31st day of December immediately preceding.

(b) Loans or extensions of credit to any person that is not an affiliate, if the CCO makes the loans or extensions of credit with the agreement or understanding that the proceeds of the transactions, in whole or in substantial part, are to be used to make loans or extensions of credit to, to purchase assets of, or to make investments in any affiliate of the CCO that is making the loans or extending the credit. This subparagraph applies to transactions that equal or exceed the lesser of three percent of the CCO’s allowed assets or 25 percent of the CCO’s combined capital and surplus, each as of the 31st day of December immediately preceding.

(c) Reinsurance agreements or modifications to reinsurance agreements, reinsurance pooling agreements and agreements in which the reinsurance premium or a change in the CCO’s liabilities, the projected reinsurance premium or a projected change in the CCO’s liabilities in any of the next three years equals or exceeds five percent of the CCO’s combined capital and surplus, as of the 31st day of December immediately preceding, including agreements that may require as consideration the transfer of assets from a CCO to a nonaffiliate if an agreement or understanding exists between the CCO and nonaffiliate that any portion of the assets will be transferred to one or more affiliates of the CCO.

(d) All management agreements, service contracts, tax allocation agreements, guarantees and all cost-sharing arrangements.

(e) A guarantee that a CCO makes if the guarantee is not quantifiable as to amount. If the guarantee is quantifiable as to amount, the CCO is not required to notify the Authority under this section unless the guarantee exceeds the lesser of one-half of one percent of the CCO’s admitted assets or 10 percent of surplus with respect to Members as of the 31st day of December immediately preceding.

(f) Direct or indirect acquisitions or investments in a person that controls the CCO or in an affiliate of the CCO, the amount of which, together with the CCO’s existing acquisitions or investments in the person or affiliate, exceeds two and one-half percent of the CCO’s surplus to Members.

(g) Any other material transactions specified by the Authority from time to time as transactions that may adversely affect the interests of the CCO’s Members.

(5) A notice for a transaction under subsection (3) that is an amendment to or modification of an affiliate agreement that was previously filed must include a statement of reasons for the change and an estimate of the financial impact the change would have on the CCO.

(6) A CCO shall notify the Authority informally within 30 days after a previously filed agreement has terminated, and the Authority, after receiving the notice, shall determine the type of filing the CCO must submit, if any.

(7) A CCO may not enter into one or more transactions during any 12-month period that are part of a plan or series of like transactions with persons that are within the CCO holding company system if the purpose of the separate transactions is to avoid the statutory threshold amount and thus avoid the review that would occur otherwise.

(8) In reviewing a transaction in accordance with subsection (3) of this section, the Authority shall consider whether the transaction complies with the standards set forth in subsection (1) of this section and whether the transaction may adversely affect the interests of Members.

(9) A CCO shall notify the Authority not later than the 30th day after any investment the CCO makes in any one corporation or other legal entity if the total investment the CCO holding company system makes in the corporation or other legal entity exceeds 10 percent of the corporation’s voting securities or other equivalent ownership interests.

(10) This section does not authorize or permit any transaction that, in the case of a CCO that is not a member of the same CCO holding company system, would be otherwise contrary to law.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5323 CCO HOLDING COMPANY REGULATION: Transaction Types Within Holding Company for Disclosure

(1) A CCO required to give notice of a proposed transaction pursuant OAR 410-141-5320 shall furnish the required information on Form D. Form D is set forth on the website of the Authority at https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(2) Agreements for cost sharing services and management services shall at a minimum and as applicable:

(a) Identify the person providing services and the nature of such services;

(b) Set forth the methods to allocate costs;

(c) Require timely settlement, not less frequently than on a quarterly basis, and compliance with the requirements in the Accounting Practices and Procedures Manual;

(d) Prohibit advancement of funds by the CCO to the affiliate except to pay for services defined in the agreement;

(e) State that the CCO shall maintain oversight for functions provided to the CCO by the affiliate and that the CCO shall monitor services annually for quality assurance;

(f) Define books and records of the CCO to include all books and records developed or maintained under or related to the agreement;

(g) Specify that all books and records of the CCO are and remain the property of the CCO and are subject to the control of the CCO;

(h) State that all funds and invested assets of the CCO are the exclusive property of the CCO, held for the benefit of the CCO and are subject to the control of the CCO;

(i) Include standards for termination of the agreement with and without cause;

(j) Include provisions for indemnification of the CCO in the event of gross negligence or willful misconduct on the part of the affiliate providing the services;

(k) Specify that, if the CCO is placed in receivership or seized by the Authority under ORS chapter 415:

(A) All of the rights of the CCO under the agreement extend to the receiver or the Authority, and,

(B) All books and records shall immediately be made available to the receiver or the Authority, and shall be turned over to the receiver or the Authority immediately upon the receiver or the Authority’s request;

(L) Specify that the affiliate has no automatic right to terminate the agreement if the CCO is placed in receivership pursuant to ORS chapter 415; and

(m) Specify that the affiliate shall continue to maintain any systems, programs, or other infrastructure notwithstanding a seizure by the Authority under ORS chapter 415, and shall make them available to the receiver, for so long as the affiliate continues to receive timely payment for services rendered.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, adopt filed 12/29/2024, effective 01/01/2025

Or. Admin. R. 410-141-5325 CCO HOLDING COMPANY REGULATION: Director and Officer Liability; Effect of Control of CCO Subject to Registration; Board of Directors

(1) A person’s control of a CCO that is subject to registration does not relieve the officers and directors of the CCO of any obligation or liability to which the officers and directors may otherwise be subject by law. The CCO must be managed so as to assure the CCO’s separate operating identity.

(2) This section does not preclude a CCO from having or sharing a common management, or from using personnel, property or services jointly or cooperatively, with another person under an arrangement that meets the standards set forth in OAR 410-141-5320.

(3) At least one-third of a CCO’s directors and at least one-third of the members of each committee of the CCO’s Board must be persons who are not:

(a) Officers or employees of the CCO or of any entity that controls, is controlled by or is under common control with the CCO; or

(b) Beneficial owners of a controlling interest in the voting securities of the CCO or of an entity that controls, is controlled by or is under common control with the CCO.

(4) A quorum for transacting business at a meeting of the CCO’s Board or any committee of the CCO’s Board must include at least one person with the qualifications described in paragraph (a) of this subsection.

(5) A CCO’s Board shall establish at least one committee of which the entire membership consists of persons who have the qualifications described in subsection (3) of this section. The CCO Board shall give the committee established under this subsection responsibility for:

(a) Recommending independent certified public accountants for the board to select;

(b) Reviewing the CCO’s financial condition and the scope and results of any independent or internal audit;

(d) Recommending principal officers for selection and the compensation for the principal officers; and

(e) Evaluating the principal officers’ performance.

(6) Subsections (3), (4) and (5) of this section do not apply to a CCO if the person that controls the CCO has a board of directors, and committees of the person’s board of directors, that meet the requirements set forth in subsections (3), (4) and (5) of this section.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 72-2023, minor correction filed 08/22/2023, effective 08/22/2023
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5330 CCO HOLDING COMPANY REGULATION: Annual Enterprise Risk Report

(1) Every CCO subject to registration shall file an enterprise risk report each year. The enterprise risk report must identify, to the best of the CCO’s knowledge and belief, the material risks within the holding company system of which the CCO is a part that may pose enterprise risk to the CCO.

(2) A CCO required to file an enterprise risk report pursuant to this rule shall furnish the required information on Form F. Form F is set forth on the website of the Authority at https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5335 CCO HOLDING COMPANY REGULATION: Disclaimers and Termination of Registration

(1) The Authority shall terminate the registration of any CCO which demonstrates that it no longer is a member of a CCO holding company system.

(2) A request for termination of registration claiming that a person does not, or shall not upon the taking of some proposed action, control another person (referred to as the “subject” in this section) shall contain:

(a) The number of authorized, issued and outstanding voting securities of the subject;

(b) With respect to the person whose control is denied and all affiliates of such person, the number and percentage of shares of the subject’s voting securities that are held of record or known to be beneficially owned, and the number of such shares concerning which there is a right to acquire, directly or indirectly;

(c) All material relationships and bases for affiliation between the subject and the person whose control is denied and all affiliates of such person; and

(d) A statement explaining why such person may not be considered to control the subject.

(3) A request for termination of registration shall be considered granted unless the Authority, within thirty (30) days after the Authority receives the request, notifies the registrant otherwise.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5340 CCO HOLDING COMPANY REGULATION: Forms; General Requirements

(1) Forms A, B, C, D, E and F are intended to be guides in the preparation of the statements required by OAR 410-141-5290 to OAR 410-141-5355, including but not limited to the registration provisions thereof. The forms are not intended to be blank forms that are to be filled in. The statements filed shall contain the numbers and captions of all items, but the text of the items may be omitted if the answers to the items are prepared so as to indicate clearly the scope and coverage of the items. All instructions, whether appearing under the items of the form or elsewhere, are to be omitted. Unless expressly provided otherwise, if any item is inapplicable or the answer to any item is in the negative, an appropriate statement to that effect shall be made.

(2) One complete copy of each statement, including exhibits and all other papers and documents filed as a part of the statement, shall be filed with the Authority by electronic delivery according to the terms of the CCO Contract. Each statement shall be signed and certified in the manner prescribed on the form. Unsigned copies shall be confirmed. If the signature of any person is affixed pursuant to a power of attorney or other similar authority, a copy of such power of attorney or other authority shall also be filed with the statement.

(3) Statements must be prepared electronically and clearly named. Exhibits and financial statements, unless specifically prepared for the filing, may be submitted in their original size. All copies of any statement, financial statements or exhibits shall be clear, easily readable, and suitable for printing. Debits in credit categories and credits in debit categories shall be designated so as to be clearly distinguishable as such on photocopies. Statements shall be in the English language and monetary values shall be stated in United States currency. If any exhibit or other paper or document filed with the statement is in a foreign language, it shall be accompanied by a translation into the English language and any monetary value shown in a foreign currency shall be converted into United States currency.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5345 CCO HOLDING COMPANY REGULATION: Forms; Incorporation by Reference, Summaries, And Omissions

(1) Information required by any item of Form A, B, D, E or F may be incorporated by reference in answer or partial answer to any other item. Information contained in any financial statement, annual report, proxy statement, statement filed with a governmental authority or any other document may be incorporated by reference in answer or partial answer to any item of Form A, B, D, E or F if the document or paper is filed as an exhibit to the statement. Excerpts of documents may be attached as exhibits if the documents are extensive. Documents currently on file with the Authority that were filed within three (3) years need not be filed as exhibits. References to information contained in exhibits or in documents already on file shall clearly identify the material and shall specifically indicate that such material is to be incorporated by reference in answer to the item. Matter shall not be incorporated by reference in any case in which the incorporation would render the statement incomplete, unclear, or confusing.

(2) If an item requires a summary or outline of the provisions of any document, only a brief statement of the pertinent provisions of the document shall be made. The summary or outline may in addition incorporate by reference particular parts of any exhibit or document currently on file with the Authority that was filed within three (3) years and may be qualified in its entirety by such reference. If two or more documents required to be filed as exhibits are substantially identical in all material respects except as to the parties thereto, the dates of execution or other details, a copy of only one of such documents need be filed, but it shall have attached a schedule identifying the omitted documents and setting forth the material details in which such documents differ from the documents of which a copy is filed.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5350 CCO HOLDING COMPANY REGULATION: Forms; Information Unknown or Unavailable and Extension of Time to Furnish

(1) Required information need be given only insofar as it is known or reasonably available to the person filing the statement. If any required information is unknown and not reasonably available to the person filing, either because obtaining it would involve unreasonable effort or expense, or because it rests peculiarly within the knowledge of another person not affiliated with the person filing, the information may be omitted. However, the person filing shall:

(a) Give such information on the subject as the person possesses or can acquire without unreasonable effort or expense, together with the sources thereof; and

(b) Include a statement either showing that unreasonable effort or expense would be involved or indicating the absence of any affiliation with the person within whose knowledge the information rests and stating the result of a request made to such person for the information.

(2) If it is impractical to furnish any required information, document, or report at the time it is required to be filed, a person may file a waiver request with the Authority:

(a) Identifying the information, document, or report in question;

(b) Stating why the filing thereof at the time required is impractical; and

(3) An waiver request submitted under subsection (2) shall be considered granted unless the Authority, within thirty (30) days after receipt thereof, enters an order denying the application.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5355 CCO HOLDING COMPANY REGULATION: Forms; Additional Information; Amendments

(1) In addition to the information expressly required to be included in Forms A, B, C, D, E and F, a person filing such forms shall include further material information, if any, as may be necessary to make the information contained in the form not misleading. The person filing may also file exhibits in addition to those expressly required by the statement. Such exhibits shall be marked to clearly indicate the subject matters to which they refer.

(2) A change to Form A, B, C, D, E and F shall include on the top of the cover page the phrase: “Change No. _____ to” and shall indicate the date of the change and not the date of the original filing.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5360 CCO INSOLVENCY AND DISSOLUTION: Access to Funds and Transition of Members and Records

(1) CCOs shall provide the Authority access to Restricted Reserve Funds if insolvency occurs.

(2) CCOs shall have written policies and procedures to ensure that if insolvency occurs, Members and related clinical records are transitioned to other CCOs or providers with minimal disruption.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605, 415.013 & 415.101-415.430
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5365 CCO INSOLVENCY AND DISSOLUTION: Hazardous Operations

(1) Without limitation or exclusion of any other authority, actions or remedies that are available to the Authority under these rules or under applicable Law, if the Authority determines that the continued operation of a CCO is hazardous to its Members or to the public in general, the Authority may issue a Notice of Intent to the CCO to take one or more of the following actions:

(a) Reduce the total amount of present and potential liability for Member services by reinsurance.

(b) Reduce, suspend or limit the volume of business being accepted or renewed.

(d) Increase the capital and surplus of the CCO.

(e) Suspend or limit the declaration and payment of dividends by the CCO to its stockholders or members.

(f) Limit or withdraw from certain investments or discontinue certain investment practices to the extent the Authority determines such action to be necessary.

(2) A CCO may file a written request for a contested case hearing within fifteen (15) days following the date of the Notice of Intent

(a) Contested case hearings shall be conducted pursuant to ORS 183.411 through ORS 183.497 and the Attorney General's Uniform and Model Rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 through OAR 137-003-0700, and the provisions of this rule.

(b) The contested case hearing shall be held within thirty business days after the date the written request for a hearing was filed.

(c) In a contested case conducted pursuant to this rule, an administrative law judge assigned by the Office of Administrative Hearings shall serve a proposed order on all parties and the Authority, unless prior to the hearing the Authority notifies the administrative law judge that a final order may be served, within 30 calendar days of the close of the evidentiary record in the contested case.

(d) The Authority shall issue a final order within 30 days of receipt of the proposed order, which may adopt some or all of the proposed order, as the Authority shall determine in its sole discretion. The final order is effective immediately upon being signed or as otherwise provided in the order.

(e) The time limits established in rule may be waived or shortened by agreement among the parties and the Authority.

(3) Without limiting the facts, conditions, circumstances or factors that the Authority may identify, evaluate or rely upon in determining whether the continued operation of a CCO could be hazardous to the CCO’s Members, its creditors or the general public, and without limiting the Authority’s discretion to make such determinations, the Authority may consider the following:

(a) Adverse findings reported in financial condition examination reports, audit reports, and actuarial opinions, reports or summaries.

(b) Whether the CCO has made adequate provision, according to presently accepted actuarial standards of practice, for the anticipated cash flows required by the contractual obligations and related expenses of the CCO, when considered in light of the assets held by the CCO with respect to such reserves and related actuarial items including but not limited the investment earnings on such assets, and the considerations anticipated to be received and retained under such contracts.

(c) The ability of a CCO’s reinsurers to perform and whether the CCO's reinsurance program provides sufficient protection for the CCO's capital and surplus after taking into account the CCO's cash flow and the classes of business written as well as the financial condition of the CCO’s reinsurers.

(d) Whether the CCO's operating loss in the last 12-month period or any shorter period of time is greater than 50 percent of the CCO's remaining capital and surplus in excess of the minimum required.

(e) Whether the CCO’s operating loss in the last 12-month period or any shorter period of time, excluding net capital gains, is greater than 20 percent of the CCO’s remaining surplus in excess of the minimum required.

(f) Whether any of the CCO’s reinsurers or any of the CCO’s other counterparty obligors, or any entity within the CCO’s holding company system is insolvent, threatened with insolvency or delinquent in payment or performance of its monetary or other obligations to the CCO, which could materially and adversely affect the solvency of the CCO.

(g) Contingent liabilities, pledges or guaranties that either individually or collectively involve a total amount that may materially and adversely affect the solvency of the CCO.

(h) Whether any "controlling person" of a CCO is delinquent in remitting amounts due the CCO.

(i) The age and collectability of receivables.

(j) Whether the management of a CCO, including officers, directors or any other person who directly or indirectly controls the operation of the CCO, fails to possess and demonstrate the competence, fitness and reputation determined by the Authority to be necessary to serve the CCO in such position.

(k) Whether management of a CCO has failed to respond to inquiries relating to the condition of the CCO or has furnished false and misleading information concerning an inquiry.

(L) Whether the CCO has failed to meet financial responsibility, accountability or filing requirements.

(m) Whether management of a CCO has filed a false or misleading sworn financial statement or has released a false or misleading financial statement to lending institutions or to the general public, or has made a false or misleading entry, or has omitted an entry of material amount in the books of the CCO.

(n) Whether the CCO has grown so rapidly and to such an extent that it lacks adequate financial and administrative capacity to meet its obligations in a timely manner.

(o) Whether the CCO has experienced or is projected to experience in the foreseeable future cash flow or liquidity issues that could materially and adversely affect the CCO’s solvency and/or prospects for continued operation.

(p) Whether management has established reserves that do not comply with minimum standards established by the CCO Contract or regulations, accounting standards, sound actuarial principles and standards of practice.

(q) Whether management of the CCO has caused the CCO to maintain materially insufficient statutory loss reserves or loss adjustment expense reserves.

(r) In respect of transactions between or among the CCO and affiliates within the CCO’s holding company system:

(A) Whether the CCO has accurately and timely reported those transactions;

(B) Whether the CCO has filed for and obtained required regulatory approvals of those transactions;

(C) Whether those transactions are fair and reasonable to the CCO, and are otherwise consistent with terms that would be available to the CCO in an unaffiliated arms-length transaction;

(D) Whether any of those transactions were for the principal benefit of an affiliate of the CCO or otherwise were not in the best interests of the CCO and its Members; and

(E) Whether those transactions otherwise comply with the procedural and substantive standards that apply under Applicable Law.

(s) Any other fact, condition or circumstance found by the Authority to be hazardous to the CCO’s Members, creditors or the general public.

(4) For the purposes of making a determination of the financial condition of a CCO under these rules or the CCO Contract, the Authority may do one or more of the following:

(a) Disregard any credit or amount receivable resulting from transactions with a reinsurer that is insolvent, impaired or otherwise subject to a delinquency proceeding.

(b) Make appropriate adjustments to asset values attributable to investments in or transactions with parents, subsidiaries or affiliates.

(c) Refuse to recognize the stated value of accounts receivable and/or amounts due from affiliates if the ability to collect receivables is speculative in view of the age of the account or the financial condition of the debtor or affiliated organization.

(d) Increase the CCO's liability in an amount equal to any contingent liability, pledge, or guarantee not otherwise included if there is a substantial risk that the CCO shall be called upon to meet the obligation undertaken within the next twelve-month period.

(5) In circumstances where the Authority determines, in its discretion, that the financial condition, operating history or future prospects of a CCO warrant such actions, the Authority may require that the CCO:

(a) Promptly provide written responses to an inquiry of the Authority for a current valuation of assets or liabilities of the CCO.

(b) In addition to the required annual and quarterly financial statements, file interim financial statements as of a particular date or with such greater frequency as the Authority may specify.

(c) Promptly produce its personnel and/or records, and/or the records and personnel of its affiliates, for examination by the Authority.

(d) Correct corporate governance practice deficiencies and adopt and utilize governance practices acceptable to the Authority.

(e) Provide a business plan to the Authority demonstrating corrective action the CCO shall take to improve its financial condition or such other conditions or deficiencies as may be identified by the Authority.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605, 415.013 & 415.101-415.430
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5370 CCO INSOLVENCY AND DISSOLUTION: Recovery From Parent Corporation Or Holding Company In The Event Of Liquidation Or Rehabilitation

(1) If an order for liquidation or rehabilitation of a CCO has been entered pursuant to ORS 415.280, the receiver appointed under the order may recover, on behalf of the CCO, from any parent corporation or holding company or person or affiliate who otherwise controlled the CCO, the amount of distributions, other than distributions of shares of the same class of stock, paid by the CCO on the CCO's capital stock, or any payment in the form of a bonus, termination settlement or extraordinary lump sum salary adjustment made by the CCO or the CCO's subsidiary to a director, officer or employee, when such a distribution or payment is made at any time during the 12 calendar months preceding the petition for liquidation, conservation or rehabilitation, as the case may be, subject to the limitations of subsections (2), (3) and (4) of this section.

(2) A distribution to which subsection (1) of this section applies is not recoverable if the parent or affiliate shows that the distribution was lawful and reasonable when paid and that the CCO did not know and could not reasonably have known that the distribution might adversely affect the ability of the CCO to fulfill the CCO's contractual obligations.

(3) Any person who was a parent corporation or holding company or a person who otherwise controlled the CCO or affiliate at the time a distribution to which subsection (1) of this section applies was paid is liable in an amount that is not more than the amount of distributions or payments received by the person under subsection (1) of this section. Any person who otherwise controlled the CCO at the time such distributions were declared is liable up to the amount of distributions the person would have received if the distributions had been paid immediately. If two or more persons are liable with respect to the same distributions, the persons are jointly and severally liable.

(4) The maximum amount recoverable under this section is the amount needed in excess of all other available assets of the impaired or insolvent CCO to pay the contractual obligations of the impaired or insolvent CCO.

(5) To the extent that any person liable under subsection (3) of this section is insolvent or otherwise fails to pay claims due from the person pursuant to subsection (3) of this section, the person's parent corporation or holding company or other person who otherwise controlled the person liable under subsection (3) of this section when the distribution was paid are jointly and severally liable for any resulting deficiency in the amount recovered from the parent corporation or holding company or person who otherwise controlled the person liable under subsection (3) of this section.

(6) If a CCO is placed into rehabilitation or liquidation and the CCO engages in transactions within its holding company system that are subject to OAR 410-141-5320, the Authority retains jurisdiction over the CCO, any interested affiliates of the CCO and the transaction for purposes of regulation and enforcement under OAR 410-141-5320.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605, 415.013 & 415.101-415.430
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5375 CCO INSOLVENCY AND DISSOLUTION: Voluntary Dissolution; Approval of Plan

(1) No CCO may be dissolved voluntarily until the Authority has approved a plan for liquidation of the CCO's assets and obligations.

(2) The plan of dissolution must provide for the reinsurance and assumption of all in-force CCO contracts to which the CCO is a party.

(3) The Authority shall require that the plan of dissolution provide adequate reserves in trust or otherwise for the satisfaction of all remaining obligations of the CCO.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605, 415.013 & 415.101-415.430
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Or. Admin. R. 410-141-5380 CIVIL PENALTIES

(1) The Director of the Oregon Health Authority may impose a civil penalty for violations of OAR 410-141-5000 to 410-141-5380 or any final order of the Authority entered under any of OAR 410-141-5000 to 410-141-5380, in an amount determined by the Authority that shall not exceed $10,000 for each offense. Each violation is a separate offense.

(2) In addition to the civil penalty specified in subsections (1), (3) and (4) of this section, the Director of the Authority may require a person that violates any provision of OAR 410-141-5000 to 410-141-5380 or any final order of the Authority entered under any of OAR 410-141-5000 to 410-141-5380, to forfeit and pay a civil penalty in an amount determined by the Authority that shall not exceed the amount by which the person profited by or through or as a result of such violation.

(3) In addition to the penalties specified in subsection (1), (2) and (4) of this section, the Director of the Authority may impose on a director or officer of a CCO or any affiliate within a CCO’s holding company system who engages in a transaction or makes an investment that has not been properly reported under, or that otherwise does not comply with OAR 410-141-5360 to 410-141-5375, who knowingly participates in or assents to the transaction or investment, or who permits another officer or an agent of the holding company system to engage in the transaction or make the investment, in the director or officer's individual capacity, a civil penalty in an amount determined by the Authority that shall not exceed $10,000.

(4) In addition to the penalties specified in subsections (1), (2) and (3) of this section, the Director of the Authority may impose a civil penalty on a CCO or other person that fails to make a required filing or demonstrate a good faith effort to comply with a filing requirement under OAR 410-141-5285 to OAR 410-141-5355 in an amount determined by the Authority that does not exceed $50,000.

(5) Civil penalties under this section shall be imposed and enforced in accordance with ORS 183.745.

(6) The provisions of this section are in addition to and not in lieu of, any other enforcement provisions imposed by law, including ORS Chapter 415, OAR Chapter 410, Division 141, or in the CCO Contract.

(7) Moneys received by the Authority under this section shall be paid to the State Treasury and credited to the General Fund.

History

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605, 415.063 & 415.109
Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430
DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025
DMAP 60-2019, adopt filed 12/18/2019, effective 01/01/2020

Division 142 HOSPICE SERVICES

Or. Admin. R. 410-142-0020 Definitions

(1) Accredited/Accreditation: A designation by an accrediting organization that a hospice program has met standards that have been developed to indicate a quality program.

(2) Ancillary staff: Staff that provides additional services to support or supplement hospice care.

(3) Assessment: Procedures by which strengths, weaknesses, problems, and needs are identified and addressed.

(4) Attending physician: A physician who is a doctor of medicine or osteopathy and is identified by the client, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the client's medical care.

(5) Bereavement counseling: Counseling services provided to the client's family before and after the client's death. Bereavement counseling is required to be offered per the Conditions of Participation and is a non-reimbursable hospice service.

(6) Bundled Rate: the Nursing Facility (NF) rate as defined in 411-070-0085.

(7) Client-family unit includes a client who has a life threatening disease with a limited prognosis and all others sharing housing, common ancestry or a common personal commitment with the client.

(8) Conditions of Participation (CoPs): The applicable federal regulations that hospice programs are required to comply with in order to participate in the federal Medicare and Medicaid programs.

(9) Coordinated: When used in conjunction with the phrase "hospice program," means the integration of the interdisciplinary services provided by client-family care staff, other providers and volunteers directed toward meeting the hospice needs of the client.

(10) Coordination of Care (COC): The federal regulations for coordination of client care between the hospice and the nursing facility that hospice programs are required to comply with in order to serve hospice clients in a nursing facility and participate in the federal Medicare and Medicaid programs.

(11) Coordinator: A registered nurse designated to coordinate and implement the care plan for each hospice client.

(12) Counseling: A relationship in which a person endeavors to help another understand and cope with problems as a part of the hospice plan of care.

(13) Curative: Medical intervention used to ameliorate the disease.

(14) Dying: The progressive failure of the body systems to retain normal functioning, thereby limiting the remaining life span.

(15) Family: The relatives and/or other significantly important persons who provide psychological, emotional, and spiritual support of the client. The "family" need not be blood relatives to be an integral part of the hospice care plan.

(16) Hospice: A public agency or private organization or subdivision of either that is primarily engaged in providing care to terminally ill clients, and is certified by the federal Centers for Medicare and Medicaid Services as a program of hospice services meeting current standards for Medicare and Medicaid reimbursement and Medicare Conditions of Participation; and currently licensed by the Oregon Health Authority (Authority), Public Health Division.

(17) Hospice continuity of care: Services that are organized, coordinated and provided in a way that is responsive at all times to client/family needs, and which are structured to assure that the hospice is accountable for its care and services in all settings according to the hospice plan of care.

(18) Hospice routine home care: Formally organized services designed to provide and coordinate hospice interdisciplinary team services to client/family in the place of residence. The hospice will deliver at least 80 percent of the care in the place of residence.

(19) Hospice philosophy: Hospice recognizes dying as part of the normal process of living and focuses on maintaining the quality of life. Hospice exists in the hope and belief that through appropriate care and the promotion of a caring community sensitive to their needs, clients and their families may be free to attain a degree of mental and spiritual preparation for death that is satisfactory to them.

(20) Hospice Program: A coordinated program of home and inpatient care, available 24 hours a day, that uses an interdisciplinary team of personnel trained to provide palliative and supportive services to a client-family unit experiencing a life threatening disease with a limited prognosis. A hospice program is an institution for purposes of ORS

(21) Hospice Program registry: A registry of all licensed hospice programs maintained by the Authority, Public Health Division.

(22) Hospice services: Items and services provided to a client/family unit by a hospice program or by other clients or community agencies under a consulting or contractual arrangement with a hospice program. Hospice services include home care, inpatient care for acute pain and symptom management or respite, and bereavement services provided to meet the physical, psychosocial, emotional, spiritual and other special needs of the client/family unit during the final stages of illness, dying and the bereavement period.

(23) Illness: The condition of being sick, diseased or with injury.

(24) Interdisciplinary team: A group of individuals working together in a coordinated manner to provide hospice care. An interdisciplinary team includes, but is not limited to, the client-family unit, the client's attending physician or clinician and one or more of the following hospice program personnel: Physician, nurse practitioner, nurse, hospice aide (nurse's aide), occupational therapist, physical therapist, trained lay volunteer, clergy or spiritual counselor, and credentialed mental health professional such as psychiatrist, psychologist, psychiatric nurse or social worker.

(25) Medical director: The medical director must be a hospice employee who is a doctor of medicine or osteopathy who assumes overall responsibility for the medical component of the hospice's client care program.

(26) Medicare certification: Licensed and certified by the Authority, Public Health Division as a program of services eligible for reimbursement.

(27) Nursing facility: A facility licensed and certified by the Department of Human Services (Department) as a nursing facility and defined in OAR 411-070.

(28) Nursing facility services: The bundled rate of services which incorporates all services, including room and board, for which the nursing facility is paid per OAR 411-070.

(29) Pain and Symptom Management: For the hospice program, the focus of intervention is to maximize the quality of the remaining life through the provision of palliative services that control pain and symptoms. Hospice programs recognize that when a client/family is faced with terminal illness, stress and concerns may arise in many aspects of their lives. Symptom management includes assessing and responding to the physical, emotional, social and spiritual needs of the client/family.

(30) Palliative services: Comfort services of intervention that focus primarily on reduction or abatement of the physical, psychosocial and spiritual symptoms of terminal illness. Palliative therapy:

(a) Active: Is treatment to prolong survival, arrest the growth or progression of disease. The person is willing to accept moderate side-effects and psychologically is fighting the disease. This person is not likely to be a client for hospice;

(b) Symptomatic: Is treatment for comfort, symptom control of the disease and improves the quality of life. The person is willing to accept minor side-effects and psychologically wants to live with the disease in comfort. This person would have requested and been admitted to a hospice.

(31) Period of crisis: A period in which the client requires continuous care to achieve palliation or management of acute medical symptoms.

(32) Physician designee: Means a doctor of medicine or osteopathy designated by the hospice who assumes the same responsibilities and obligations as the medical director when the medical director is not available.

(33) Primary caregiver: The person designated by the client or representative. This person may be family, a client who has personal significance to the client but no blood or legal relationship (e.g., significant other), such as a neighbor, friend or other person. The primary caregiver assumes responsibility for care of the client as needed. If the client has no designated primary caregiver the hospice may, according to client program policy, make an effort to designate a primary caregiver.

(34) Prognosis: The amount of time set for the prediction of a probable outcome of a disease.

(35) Representative: An individual who has been authorized under state law to terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill client who is mentally or physically incapacitated.

(36) Terminal illness: An illness or injury which is forecast to result in the death of the client, for which treatment directed toward cure is no longer believed appropriate or effective.

(37) Terminally Ill means that the client has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

(38) Volunteer: An individual who agrees to provide services to a hospice program without monetary compensation.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 30-2013, f. & cert. ef. 6-27-13
DMAP 18-2013(Temp), f. 4-11-13, cert. ef. 5-1-13 thru 10-28-13
DMAP 40-2011, f. 12-15-11, cert. ef. 1-1-12
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 18-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 34-2000, f. 9-29-00, cert. ef. 10-1-00
HR 16-1995, f. & cert. ef. 8-1-95
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0040 Eligibility for the Hospice Services

(1) Hospice services are covered for clients who have:

(a) Been certified as terminally ill in accordance with OAR 410-142-0060; and

(b) Have Oregon Health Plan (OHP) Plus benefit package coverage.

(2) Providers must bill Medicare for hospice services for clients with Medicare Part A coverage. Medicare’s payment is considered payment in full.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 40-2011, f. 12-15-11, cert. ef. 1-1-12
OMAP 43-2005, f. 9-2-05, cert. ef. 10-1-05
HR 16-1995, f. & cert. ef. 8-1-95
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0060 Certification of Terminal Illness

(1) In order to receive reimbursement from the Division of Medical Assistance Programs (Division), the hospice must obtain and retain a physician’s written certification of a client’s terminal illness in accordance with the following procedures. Division will not pay for services provided prior to certification.

(2) The attending physician is a doctor of medicine or osteopathy or a nurse practitioner and is identified by the client at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the client’s medical care. A nurse practitioner serving as the attending physician may not certify or re-certify the terminal illness.

(3) Certifications may be completed up to two weeks before hospice care is elected.

(4) The certification of a client who elects hospice is based on the physician’s or medical director’s clinical judgment regarding the normal course of the client’s illness and must include:

(a) The statement that the client’s medical prognosis indicates a life expectancy of six months or less if the terminal illness runs its normal course; and

(b) Clinical information and other documentation which support the medical prognosis must accompany the certification and be filed in the medical record with the certification.

(5) A written certification signed by the physician(s) must be on file in the hospice client’s record prior to submission of a claim to Division for all benefit periods.

(6) For the initial period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the client’s attending physician (if the client has an attending physician). If the written certification is not dated, a notarized statement or some other acceptable documentation may be obtained to verify the actual certification date.

(7) For any subsequent periods, the hospice must obtain, no later than two calendar days after the first date of each period, a written certification from the medical director of the hospice or the physician member of the hospice’s interdisciplinary group. If the hospice cannot obtain written certification within two calendar days, it must obtain oral certification within two calendar days.

(8) The requirements specified in this rule also apply to clients who had been previously discharged during a benefit period and are again being certified for hospice care.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 34-2006, f. 9-15-06
OMAP 58-2002, f. & cert. ef. 10-1-02
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0080 Informed Consent

A hospice must demonstrate respect for an individual's rights by ensuring that an informed consent form has been obtained for every individual, either from the individual or representative as defined in OAR 410-142-0020. The form must specify the type of care and services that may be provided as hospice care during the course of the illness.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0100 Election of Hospice Care

(1) An individual who meets the eligibility requirements of OAR 410-142-0040 may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, his or her representative may file the election statement.

(2) The election statement must include the following:

(a) Identification of the particular hospice that will provide care to the individual;

(b) The individual's or representative's acknowledgment that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as related to the individual's terminal illness;

(c) Except for children (see 410-124-0110), acknowledgment that certain otherwise covered services are waived by the election. Election of a hospice benefit means that the Division of Medical Assistance Programs (Division) will only reimburse the hospice for those services included in the hospice benefit;

(d) The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement;

(e) The signature of the individual or representative.

(3) Re-election of hospice benefits. If an election has been revoked in accordance with OAR 410-142-0160, the individual (or his or her representative if the individual is mentally or physically incapacitated) may at any time file an election, in accordance with this section, for any other election period that is still available to the individual.

(4) File the election statement in the medical record.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0110 Concurrent Care for Children

(1) Under Section 2302 of the Affordable Care Act, Medicaid or Children’s Health Insurance Program (CHIP) eligible children are eligible to receive curative treatment upon the election of the hospice benefit.

(2) The criteria for receiving hospice services does not change for children eligible for Medicaid and CHIP programs. However these children may now receive hospice services without forgoing any other service to which the child is entitled under Medicaid for treatment of the terminal condition.

(3) All other eligibility, coverage, and hospice rules for the Division of Medical Assistance Programs apply.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11

Or. Admin. R. 410-142-0120 Duration of Hospice Care

(1) An eligible individual may elect to receive hospice care during one or more of the following election periods:

(a) An initial 90-day period;

(b) A subsequent 90-day period;

(2) An election to receive hospice care will be considered to continue through the initial election period and through the subsequent election periods without a break in care as long as the individual:

(a) Remains in the care of a hospice; and

(b) Does not revoke the election under the provisions of OAR 410-142-0160.

(3) For the duration of an election of hospice care, an individual waives all rights to the Division of Medical Assistance Programs (Division) payments for the following services:

(a) Hospice care provided by a hospice other than the hospice designated by the individual, unless provided under arrangements made by the designated hospice;

(b) Any covered services related to the treatment of the terminal condition for which hospice care was elected or a related condition, or services equivalent to hospice care.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0140 Changing the Designated Hospice

(1) An individual or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received.

(2) The change of the designated hospice is not a revocation of the election for the period in which it is made.

(3) To change the designation of hospice programs, the individual or representative must file, with the hospice from which care has been received and with the newly designated hospice, a statement that includes the following:

(a) The name of the hospice from which the individual has received care and the name of the hospice from which he or she plans to receive care;

(b) The date the change is to be effective.

(4) The statement shall be kept on file in the medical record.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 16-1995, f. & cert. ef. 8-1-95
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0160 Revoking the Election of Hospice Care

(1) An individual or representative may revoke the individual's election of hospice care at any time during an election period.

(2) Revocation Procedure: To revoke the election of hospice care, the individual or representative must file with the Hospice a statement to be placed in the medical record that includes the following information:

(a) A signed statement that the individual or representative revokes the individual's election for coverage of hospice care for the remainder of that election period;

(b) The date that the revocation is to be effective. (An individual or representative may not designate an effective date earlier than the date that the revocation is made.)

(3) An individual, upon revocation of the election of coverage of hospice care for a particular election period:

(a) Is no longer covered for hospice care;

(b) Resumes eligibility for all covered services as before the election to hospice; and

(c) May at any time elect to receive hospice coverage for any other hospice election periods he or she is eligible to receive, in accordance with OAR 410-142-0120.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 34-2000, f. 9-29-00, cert. ef. 10-1-00
HR 16-1995, f. & cert. ef. 8-1-95
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0180 Plan of Care

A written plan of care must be established and maintained for each individual admitted to a hospice program, and the care provided to an individual must be in accordance with the plan:

(1) Establishment of Plan. The plan is established by the attending physician, the medical director or physician designee and interdisciplinary group prior to providing care.

(2) Content of Plan. The plan must include an assessment of the individual’s needs and identification of the services including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the patient’s and family’s needs.

(3) Review of Plan. The plan must be reviewed and updated, at intervals specified in the plan, by the attending physician, the medical director or physician designee and interdisciplinary group. These reviews must be documented.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0200 Interdisciplinary Group

The hospice must designate an interdisciplinary group or groups composed of individuals who provide or supervise the care and services offered by the hospice:

(1) Composition of group. The hospice must have an interdisciplinary group or groups composed of or including at least the following individuals who are employees of the hospice, or, in the case of a doctor, be under contract with the hospice:

(a) A doctor of medicine or osteopathy;

(b) A registered nurse;

(d) A pastoral or other counselor.

(2) Role of interdisciplinary group. Members of the group interact on a regular basis and have a working knowledge of the assessment and care of the patient/family unit by each member of the group. The interdisciplinary group is responsible for:

(a) Participation in the establishment of the plan of care;

(b) Provision or supervision of hospice care and services;

(d) Establishment of policies governing the day-to-day provision of hospice care and services.

(3) If a hospice has more than one interdisciplinary group, it must document in advance the group it chooses to execute the functions described in section (2) of this rule;

(4) Coordinator. The hospice must designate a registered nurse to coordinate the implementation of the plan of care for each patient.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0220 Requirements for Coverage

To be covered, hospice services must meet the following requirements:

(1) They must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions.

(2) The individual must elect hospice care in accordance with OAR 410-142-0100 and a plan of care must be established as set forth in 410-142-0180 before services are provided.

(3) The services must be consistent with the plan of care.

(4) A certification that the individual is terminally ill must be completed as set forth in OAR 410-142-0060.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0225 Signature Requirements

(1) The Division of Medical Assistance Programs (Division) requires practitioners to sign for services they order. This signature shall be handwritten or electronic, (or facsimiles of original written or electronic signatures for terminal illness for hospice) and it must be in the client’s medical record.

(2) The ordering practitioner is responsible for the authenticity of the signature.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 37-2006, f. 12-15-06, cert. ef. 1-1-07

Or. Admin. R. 410-142-0240 Hospice Core Services

The following services are covered hospice services when consistent with the plan of care and must be provided in accordance with recognized standards of practice:

(1) Nursing services. The hospice must provide nursing care and services by or under the supervision of a registered nurse:

(a) Nursing services must be directed and staffed to assure that the nursing needs of the patient are met;

(b) Patient care responsibilities of nursing personnel must be specified;

(2) Medical social services. Medical social services must be provided by a qualified social worker, under the direction of a physician;

(3) Physician services. In addition to palliative and management of terminal illness and related conditions, physician employees, contractors or volunteers of the hospice, including the physician member(s), of the interdisciplinary group, must also meet the general medical needs of the patient to the extent these needs are not met by the attending physician:

(a) Reimbursement for physician or nurse practitioner supervisory and interdisciplinary group services for those physicians or nurse practitioners employed by the hospice agency is included in the rate paid to the agency;

(b) Reimbursement of attending physician or nurse practitioner services for those physicians not employed by the hospice agency is according to the Division of Medical Assistance Programs (Division) fee schedule. These physicians or nurse practitioners must bill the Division for their services;

(c) Reimbursement of attending physician or nurse practitioner services (not including supervisory and interdisciplinary group services) for those physicians or nurse practitioners employed by the hospice agency is according to the Division fee schedule. These physicians or nurse practitioners must bill the Division for their services;

(d) Reimbursement of the hospice for consulting physician services furnished by hospice employees or by other physicians under arrangements by the hospice is included in the rate paid to the agency.

(4) Counseling services. Counseling services must be available to both the patient and the family. Counseling includes bereavement counseling provided after the patient's death as well as dietary, spiritual and any other counseling services for the patient and family provided while the individual is enrolled in the hospice;

(5) Short-term inpatient care. Inpatient care must be available for pain control, symptom management and respite purposes;

(6) Medical appliances and supplies:

(a) Includes drugs and biologicals as needed for the palliation and management of the terminal illness and related conditions;

(b) Drugs prescribed for conditions other than for the palliation and management of the terminal illness are not covered under the hospice program.

(7) Hospice aide and homemaker services;

(8) Physical therapy, occupational therapy, and speech-language pathology services;

(9) Other services. Other services specified in the plan of care that are covered by the Oregon Health Plan (OHP).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0260 Hospice Level of Care

(1) Each day of hospice care is classified into one of five levels of care. The level of care determines the payment for each day of hospice benefit:

(a) Routine Home Care. A routine home care day is a day on which a patient who has elected to receive hospice care is in a place of residence and is not receiving continuous home care;

(b) Continuous Home Care. A continuous home care day is a day on which a patient who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Home health aid or homemaker services or both may also be provided on a continuous basis. Continuous home care is only furnished during brief periods of crisis as necessary to maintain the terminally ill individual at home. Nursing care must be provided by a registered nurse or a licensed practical nurse and a nurse must be providing care for more than half of the period of care. A minimum of eight hours of care must be provided during a 24-hour day, which begins and ends at midnight. When fewer than 8 hours of nursing care are required, the services are covered as routine home care rather than continuous home care;

(c) In-Home Respite Care. An in-home respite care day is a day on which short-term in-home care is provided to the patient only when necessary to relieve the family members or other persons caring for the patient at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. In-home respite care will be provided at the level necessary to meet the patient's need, with a minimum of eight hours of care provided in a 24-hour day, which begins and ends at midnight. Home health aide/CNA or homemaker services or both may be utilized for providing in-home respite care;

(d) Inpatient Respite Care. An inpatient respite care day is a day on which short-term inpatient care is provided to the patient only when necessary to relieve the family members or other persons caring for the patient at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. Payment for the sixth, and any subsequent days, is to be made at the routine home care rate. Respite care may not be provided when the hospice patient is a nursing home resident;

(e) General Inpatient Care. A general inpatient care day is a day on which a hospice patient receives care in an inpatient facility for pain control, acute or chronic symptom management, or other procedures which cannot be managed or provided in any other setting.

(2) Inpatient care must be provided by a facility that has an agreement with the hospice:

(a) A hospice capable of providing inpatient care;

(b) A hospital; or

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 58-2002, f. & cert. ef. 10-1-02
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0280 Recipient Benefits

An individual who has elected to receive hospice care remains entitled to receive other services not included in the hospice benefit. These services are subject to the same rules as for non-hospice clients. Typical services used that are not covered by the hospice benefit include:

(1) Attending physician care (e.g. office visits, hospital visits, etc.);

(2) Medical transportation;

(3) Any services, drugs or supplies for a condition other than the recipient's terminal illness or a related condition (e.g. broken leg, pre-existing diabetes).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11
HR 28-1997, f. 12-31-97, cert. ef. 1-1-98
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0290 Hospice Services in a Nursing Facility

(1) Pursuant to Title XIX, Section 1902 and 1905, federal statute prohibits the state from paying nursing facility (NF) providers directly for NF services when their Medicaid residents elect hospice care. In these instances, the Centers for Medicare and Medicaid Services (CMS) require the state to pay the hospice provider the additional amount equal to at least 95% of the per diem rate the state would have paid to the NF for NF services for that client in that facility.

(2) When a client resides in a NF and elects hospice care, the hospice provider and the NF must have a written contract which addresses the provision of hospice care and the method upon which the hospice will pay the NF. The hospice and the NF must maintain a copy of the completed and signed contract on file and it must be available upon request.

(3) Reimbursement when a client resides in a NF and elects hospice care:

(a) In accordance with CMS 4308.2, “when hospice care is furnished to an individual residing in a NF, the state will pay hospice an additional amount on routine home care or continuous home care days to take into account the room and board furnished by the NF. In this context, the term ‘room and board’ includes performance of personal care services, including assistance in the activities of daily living, in socializing activities, administration of medication, maintaining the cleanliness of a residents’ room, and supervision and assisting in the use of durable medical equipment and prescribed therapies,” as well as any other services considered under the bundled rate for which the NF is paid pursuant to OAR 411-070.

(b) The hospice shall bill the Division of Medical Assistance Programs (Division) directly for the hospice care provided (under routine home care, Revenue code 651, or continuous home care, Revenue code 652) and for the cost of NF services at their usual and customary rate for NF services delivered in that NF for that client;

(c) The Division shall pay the hospice provider for the hospice care provided and not to exceed 100% of the current NF basic, complex medical, pediatric, or special contract rate according to the rate schedule for NF services delivered in that NF for that client;

(d) The hospice provider must reimburse the nursing facility according to their contract and after the hospice receives payment from the Division for that NF for that client; and

(e) Reimbursement for services provided under this rule is available only if the recipient of the services is Medicaid-eligible, hospice-eligible, and been found to need NF care through the Pre-Admission Screening process under OAR 411-070-0040.

(4) NF Services Overpayment: Any payment received from the Division by a NF for services delivered after a client has elected hospice care shall adjust their claims from the day the client first elected hospice care. Failure to submit an adjustment subjects the NF to potential sanctions and all means of overpayment recovery authorized under OAR chapter 410, division 120.

(5) Coordination of Care (COC) must be provided according to CMS Conditions of Participation (CoPs), 42CFR418.112 for hospice and nursing facilities.

(6) Coordinated Care Organization (CCO) and Prepaid Health Plan (PHP) clients who reside in a NF and elect hospice care shall remain in the CCO and PHP for all care other than hospice services in the NF. Hospice services for a resident in a NF shall be excluded from CCO and PHP capitation and the hospice must bill the Division directly for payment of hospice and NF services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 30-2013, f. & cert. ef. 6-27-13
DMAP 18-2013(Temp), f. 4-11-13, cert. ef. 5-1-13 thru 10-28-13
DMAP 34-2012, f. & cert. ef. 7-20-12

Or. Admin. R. 410-142-0300 Hospice Reimbursement and Limitations

(1) The Division recalculates its hospice rates annually. When billing for hospice services, the provider must bill the usual charge or the rate based upon the geographic location in which the care is furnished, whichever is lower. See hospice rates on the Oregon Health Authority (Authority) website at: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospice.aspx.

(2) Rates:

(a) The Division bases its rates on the methodology used in setting Medicare rates, adjusted to disregard cost offsets attributable to Medicare coinsurance amounts;

(b) Under the Medicaid hospice benefit regulations, the Division cannot impose cost sharing for hospice services rendered to Medicaid recipients;

(c) The Division sets rates no lower than the rates used under Part A of Title XVIII of the Social Security Act (Medicare);

(d) The Division uses prospective hospice rates;

(e) The Division makes no retroactive adjustments other than the optional application of the cap on overall payments and the limitation on payments for inpatient care, if applicable.

(3) With the exception of payment for physician services, the Division reimburses providers of hospice services for each day of care at one of five predetermined rates. Rates are based on intensity and type of care, which the Division defines as:

(a) Routine home care. The Division pays the hospice the routine home care rate for each day that the client is under the care of the hospice and that the Division does not reimburse at another rate. The Division pays this rate without regard to the volume or intensity of services provided on any given day;

(b) Continuous home care. The Hospice must provide a minimum of eight hours of continuous home care per day to receive the continuous home care rate:

(A) The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate;

(B) The Division pays the hospice for every hour or part of an hour of continuous care furnished up to a maximum of 24 hours a day.

(c) Inpatient respite care. The Division pays the hospice at the Inpatient Respite Care rate for each day on which the client is in an approved inpatient facility and is receiving respite care:

(A) The Division pays for inpatient respite care for a maximum of five days at a time, including the date of admission but not counting the date of discharge;

(B) The Division pays for the sixth and any subsequent days at the routine home care rate.

(d) General inpatient care. The Division pays providers at the general inpatient rate when general inpatient care is provided;

(e) In-home respite care. An in-home respite care day is a day on which short-term in-home care is provided to the client only when necessary to relieve the family members or other persons caring for the client at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. In-home respite care will be provided at the level necessary to meet the client's need, with a minimum of eight hours of care provided in a 24-hour day, which begins and ends at midnight. Hospice aide/CNA or homemaker services or both may be utilized for providing in-home respite care.

(4) On the day of discharge from an inpatient unit, the Division pays the appropriate home care rate unless the client dies as an inpatient. When the client is discharged deceased, the Division pays the appropriate inpatient rate (general or respite) for the discharge date.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 63-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 36-2010, f. 12-15-10, cert. ef. 1-1-11
OMAP 34-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 43-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 90-2004, f. 11-24-04, cert. ef. 12-16-04
OMAP 79-2004(Temp), f. & cert. ef. 10-1-04 thru 3-15-05
OMAP 66-2004, f. 9-13-04, cert. ef. 10-1-04
OMAP 86-2003, f. 11-25-03 cert. ef. 12-1-03
OMAP 80-2003(Temp), f. & cert. ef. 10-10-03 thru 3-15-04
OMAP 15-2003, f. & cert. ef. 2-28-03
OMAP 41-2002(Temp), f. & cert. ef. 10-1-02 thru 3-15-03
OMAP 65-2001, f. 12-28-01, cert. ef. 1-1-02
OMAP 55-2001(Temp), f. 10-31-01, cert. ef. 11-1-01 thru 4-15-02
OMAP 34-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 40-1999, f. & cert. ef. 10-1-99
OMAP 47-1998, f. & cert. ef. 12-1-98
HR 16-1995, f. & cert. ef. 8-1-95
HR 9-1994, f. & cert. ef. 2-1-94

Or. Admin. R. 410-142-0380 Death With Dignity

(1) Death with dignity services are defined in the Division of Medical Assistance Programs (Division) Medical-Surgical Services and Pharmaceutical Services program rules.

(2) All death with dignity services must be billed directly to Division, even if the client is in a prepaid health plan (PHP).

(3) Death with dignity services are not included in the hospice care per diem payment.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 43-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 34-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 40-1999, f. & cert. ef. 10-1-99

Division 144 WORKFORCE DEVELOPMENT PROGRAMS

Or. Admin. R. 410-144-0000 Purpose

These rules outline the requirements for participation in three different Workforce Development programs for supplemental payment through Medicaid which were enacted by the Oregon legislature under Senate Bill 800 (Enrolled 2021 Regular Session), House Bill 3396 (Enrolled 2023 Regular Session), House Bill 4002 (Enrolled 2024 Regular Session) and House Bill 2024 (Enrolled 2025 Regular Session). The Essential Workforce Healthcare Program (EWHP), the Essential Workforce Development Program (EWDP) also known as CareWorks Supplemental Payment program, and the United We Heal Supplemental Payment Program (UWHP) were established with the goal of developing certain segments of the healthcare workforce in this State. Eligible employers that participate in an EWHP, EWDP, or UWHP may be eligible to receive supplemental Medicaid payments by supporting the recruitment, retention and development of health care professionals through programs approved by the legislature such as providing health care benefits; on-the-job training; apprenticeship and mentorship opportunities; increased wages and better health care benefits, and improved workplace safety standards to the employees of their facilities in accordance with the rules in this Division 144.

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 414.033, 735.520, OL 2021 ch. 595, HB 2024 (2025), HB 4002 (2024), HB 3396 (2023) & SB 800 (2021)
DMAP 83-2025, amend filed 11/24/2025, effective 12/01/2025
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0005 Definitions

(1) “Employee Retirement Income Security Act of 1974 (ERISA)” means the federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans.

(2) “Essential Workforce Health Care Fund (EWHF)” means a jointly administered employee welfare benefit plan governed by ERISA and applicable law that has been established for the purpose of providing health and related benefits to employees of participating employers and their beneficiaries and under the conditions specified in the EWHF Plan in accordance with SB 800 (2021).

(3) “Essential Workforce Development Program (EWDP)” means a Medicaid supplemental payment program for qualified nursing facilities (NFs) authorized in the Medicaid State Plan amendment as the CareWorks Supplemental Payment Program. Supplemental payments shall be made to qualified nursing facilities participating in a qualified labor-management training trust that expand on-the-job training, apprenticeship opportunities and other programs that support the development of NF health care professionals in accordance with HB 3396 and SB 1049 (2023).

(4) “United We Heal Supplemental Payment Program (UWHP)” means a supplemental Medicaid assistance program for eligible behavioral health care providers (BHCP) to access employee recruitment, retention and development opportunities by participating in a labor-management training trust that meets the requirements outlined in House Bill 4002 (Enrolled 2024 Regular Session) and as further detailed in the rules in this Division 144.

(5) “Qualified Labor Management Training Trust” means a joint labor management training trust with

(a) equal voting rights of labor and management trustees;

(b) provides high quality education, training and benefits to health care workers across multiple nursing facilities and behavioral healthcare providers statewide;

(d) agrees to use Net Payments exclusively for the benefit of Oregon nursing facilities or Oregon behavioral health care providers.

(6) “Facility” means a facility that is:

(a) A long-term care facility licensed under ORS 441.020;

(b) A residential facility as defined in ORS 443.400; or

(7) “Authority” means Oregon Health Authority.

(8) “Participating employer” means an operator of a facility that:

(a) Is a participating provider in the state medical assistance program (defined in OAR 410-120-0000);

(b) Elects to participate in the Oregon Essential Workforce Health Care Program; and

(9) “Nursing Facility” means a long-term care facility licensed under ORS 441.020.

(10) “Qualified Nursing Facility” means an operator that:

(a) Is a participating provider in the state medical assistance program (defined in OAR 410-120-0000);

(b) Has received a Medicaid payment for a nursing facility claim for services provided during the effective dates of payment;

(d) Participates in a labor-management training trust that supports the development of health care professionals during the effective date; and

(e) Has a memorandum of understanding with the Authority that specifies how the supplemental payments shall be used to support training health care workers.

(11) “Behavioral Health Care Provider” means providers certified under OAR 309-008-0250 to provide behavioral health treatment services.

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033, OL 2021 ch. 595, HB 2024 (2025), HB 4002 (2024), HB 3396 (2023) & SB 800 (2021)
DMAP 83-2025, amend filed 11/24/2025, effective 12/01/2025
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0010 Eligibility

(1) Requirements for an employer to be eligible to participate in the Essential Workforce Health Care Program include that the employer shall:

(a) Have a signed memorandum of understanding with the Oregon Health Authority (Authority) that specifies how the supplemental payments must be used;

(b) Agree to participate in evidence-based workforce and quality of care improvements; and

(2) Requirements for a qualified nursing facility to participate in the Essential Workforce Development Program include that the facility shall:

(a) Have a signed memorandum of understanding with the Authority that specifies how the supplemental payments must be used to support training health care workers;

(b) Annually report workforce development metrics;

(d) Have received a Medicaid payment for a nursing facility claim for services provided during the effective dates of payment;

(e) Be a privately-owned nursing facility; and

(f) Participate in a labor-management training trust that supports the development of health care professionals during the effective dates.

(3) Requirements for a behavioral health care provider to participate in the United We Heal Supplemental Payment Program include that the provider shall:

(a) Have a signed memorandum of understanding with the Authority that specifies how the supplemental payments must be used to access apprenticeship and training programs and opportunities to increase the available behavioral health care workforce;

(b) Annually report apprenticeship and training metrics;

(c) Have received a Medicaid payment for a behavioral health care provider claim for services provided during the effective dates of payment; and

(d) Participate in a labor-management training trust that supports the recruitment, retention and development of behavioral health care professionals during the effective dates.

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033, OL 2021 ch. 595, HB 2024 (2025), HB 4002 (2024), HB 3396 (2023) & SB 800 (2021)
DMAP 83-2025, amend filed 11/24/2025, effective 12/01/2025
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0020 Memorandum of Understanding

All participating employers that receive a supplemental payment under these programs shall sign a Memorandum of Understanding with the Authority. The Memorandum of Understanding shall document the requirements and responsibilities for using the supplemental payments to provide employee recruitment, retention and development support as appropriate to the program through some of the following: increased wages, better health care benefits, improved workplace safety standards, on-the-job training, apprenticeship opportunities, educational opportunities and/or other approved programs that support the development of health care professionals, including medical technicians, certified nursing assistants, phlebotomists, pre-apprentices, apprentices, Certified Alcohol and Drug Counselors (CADC), Qualified Mental Health Associates (QMHA), and/or Qualified Mental Health Professionals (QMHP).

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033, OL 2021 ch. 595, HB 2024 (2025), HB 4002 (2024), HB 3396 (2023) & SB 800 (2021)
DMAP 83-2025, amend filed 11/24/2025, effective 12/01/2025
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0025 Use of Supplemental Payments

Participating employers who receive supplemental payments under the EWHP, EWDP, or UWHP must use the supplemental payments as outlined in this rule and as further detailed in the MOU entered into with the Authority.

(1) Payments under Essential Workforce Health Care Program must be used to provide health care benefits to employees of the participating facilities through the Essential Workforce Health Care Fund (EWHF).

(2) Participating employers use of the supplemental payments are subject to the requirements established by the Essential Workforce Health Care Fund (EWHF).

(3) Payments under Essential Workforce Development Program (CareWorks) must be used to provide apprenticeships, on-the-job training, and other approved programs to employees of the participating facilities through an Eligible Labor Management Training Trust.

(4) Qualified nursing facility’s use of the supplemental payments are subject to the requirements established by an Eligible Labor Management Training Trust.

(5) Payments under United We Heal Supplemental Payment Program must be used to provide recruitment, retention and development opportunities such as increases in wages, better health care benefits, and improved workplace safety standards; pre-apprenticeships, apprenticeships, and on-the-job training; and other approved programs to employees of the participating providers through an Eligible Labor Management Training Trust.

(6) Eligible Behavioral Health Care Providers use of the supplemental payments is subject to the requirements established by an Eligible Labor Management Training Trust.

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033, OL 2021 ch. 595, HB 2024 (2025), HB 4002 (2024), HB 3396 (2023) & SB 800 (2021)
DMAP 83-2025, amend filed 11/24/2025, effective 12/01/2025
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0030 Evidence-based Workforce and Quality of Care Improvements

Participating employers in Essential Workforce Health Care Program must participate in evidence-based workforce and quality of care improvements, including all of the requirements in this rule.

(1) Workforce input into benefit design;

(2) Quantitative and qualitative reporting on impact of health care benefit on workforce;

(3) Retention strategies for workforce; and

(4) Others as mutually agreed upon by the Authority and participating employers.

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033 & OL 2021 ch. 595
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0040 Annual Reporting of Quality Metrics

(1) Essential Workforce Health Care Fund (EWHF) shall annually provide reports on the following metrics related to quality health benefits:

(a) Health benefits design, including total premium, employer/employee premium split, deductible, out-of-pocket maximum, co-pays, co-insurance;

(b) Services covered by benefit;

(d) Network adequacy;

(e) Waiting times for select services;

(f) Other measures of employee health and wellness as mutually agreed upon between the Authority and participating employers;

(g) Narrative description of significant changes from the past year or anticipated future changes;

(h) Workforce retention metrics; and

(i) Equity metrics.

(j) The report shall be due to the Authority by January 31 of each year.

(2) The Qualified Labor Management Training Trust shall annually provide reports on the following metrics related to apprenticeships, on-the-job training, and other programs contemplated in HB 3396 (2023):

(a) Number of qualified nursing facilities participating in a labor-management training trust to expand on-the-job training, apprenticeship opportunities and other programs that support the development of health care professionals;

(b) Participant demographics;

(d) Job placement wages;

(e) Retention of training participants;

(f) Equity metrics (REALD and SOGI); and

(g) Narrative description of significant changes in the participating employees from prior to training, through training, and anticipated future.

(h) The report shall be due to the Authority by January 31 of each year.

(3) The Qualified Labor Management Training Trust shall annually provide reports on the following metrics related to pre-apprenticeships, apprenticeships, on-the-job training, and other programs contemplated in HB 4002 (Enrolled 2024 regular session):

(a) Number of eligible behavioral health care providers participating in a labor-management training trust to expand on-the-job training, pre-apprentice and apprenticeship opportunities and other programs that support the development of behavioral health care professionals;

(b) Participant demographics;

(d) Increased wages and better health care benefits, provided;

(e) Improved workplace safety standards;

(f) Job placement wages;

(g) Retention of training participants;

(h) Equity metrics (REALD and SOGI); and

(i) Narrative description of significant changes in the participating employees from prior to training, through training, and anticipated future.

(j) The report shall be due to the Authority by January 31 of each year.

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033, OL 2021 ch. 595, HB 2024 (2025), HB 4002 (2024), HB 3396 (2023) & SB 800 (2021)
DMAP 83-2025, amend filed 11/24/2025, effective 12/01/2025
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0050 Supplemental Payments Methodology

Supplemental payments are determined using the following methods:

(1) The aggregate available supplemental payment amount for privately-owned Nursing Facilities (NFs) is calculated for each aggregate Medicaid supplemental payment limit calculation period by taking the difference between the aggregate upper payment limit (UPL) from paragraph (a) of this subsection and the aggregate Medicaid payment from paragraph (b) of this subsection.

(a) The aggregate upper payment limit for privately-owned NFs, as presented in the most recently completed Medicaid NF UPL calculation submitted to CMS, shall be calculated in accordance with the Medicaid UPL provisions codified at Title 42 CFR § 447.272 as follows:

(A) Determine aggregate costs under Medicare cost principles using the most recently filed or settled CMS 2540 skilled nursing facility cost reports for privately-owned NFs.

(B) Determine the per diem cost by dividing the aggregate costs from subparagraph (A) of this paragraph by total days of service associated with the same cost reports.

(C) Extract Medicaid days of service for privately-owned NFs from the state’s Medicaid Management Information System (MMIS) for the cost reporting periods associated with the cost reports described in clause (A) of this subparagraph.

(D) Determine aggregate Medicaid costs by multiplying the per diem Medicaid cost from section (B) of this paragraph by Medicaid days of service from section 1(a)(C) of this rule.

(b) The aggregate Medicaid payment is equal to sum of Medicaid payments for privately-owned NFs from the aggregate Medicaid supplemental payment limit calculation period. Payment data includes Medicaid regular per diem payments, per diem drug payments, and per diem client contributions.

(2) The aggregate available supplemental payment amount is not to exceed the lower of 95 percent of the aggregate available supplemental payment amount for privately owned NFs from section (1) of this rule and the general fund revenue allocated to the program plus associated federal matching funds.

(3) The state may further reduce the aggregate available supplement payment amount from section (2) of this rule if the aggregate upper payment limit for privately-owned NFs from section (1)(a) of this rule is projected to decrease between the aggregate Medicaid supplemental payment limit calculation period and the federal fiscal year within which the applicable NF-level Medicaid supplemental payment limit calculation period falls.

(4) Methodology to calculate NF-specific supplemental payment amounts:

(a) Divide the aggregate available supplemental payment amount from section (2) of this rule by a minimum of two (2);

(b) Extract Medicaid days of service for privately-owned NFs that have qualified for a supplemental payment from the state’s MMIS for the NF-level Medicaid supplemental payment limit calculation period;

(c) The allocation percentage for each qualifying NF shall be determined by dividing the individual NF’s total Medicaid days from section (2) of this rule by the aggregate sum of all qualifying NFs’ Medicaid days from the same section;

(d) The NF-specific supplemental payment for the NF-level Medicaid supplemental payment limit calculation period shall equal the aggregate available supplemental payment amount from subsection (4)(a) of this rule multiplied by the NF’s allocation percentage from subsection (4)(c) of this rule.

(e) The supplemental payment does not exceed applicable Federal upper payment limit requirements.

(5) Methodology to calculate eligible behavioral health care provider (BHCP) supplemental payment amounts.

(a) Establish a payment pool of total available supplemental payment amount for all qualifying BHCP which is equal to the general fund revenue appropriated plus associated federal matching funds.

(b) Extract Medicaid payments for eligible BHCPs determined per Eligibility rule 410-144-0010 section (4)(a-d) from the state’s Medicaid Management Information System (MMIS) for effective dates of payments.

(c) The allocation percentage for each eligible BHCP will be determined by dividing the BHCP’s total Medicaid revenue from subsection (4)(b) of this rule by the aggregate sum of all eligible BHCPs’ Medicaid revenue from the same subsection;

(d) The BHCP-specific supplemental payment will equal the total available supplemental payment amount from subsection (4)(a) of this rule multiplied by the allocation percentage from subsection (4)(c) of this rule.

(e) The supplemental payment does not exceed applicable Federal upper payment limit requirements.

History

Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033 & OL 2021 ch. 595
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Or. Admin. R. 410-144-0060 Oversight

All payments authorized for these Programs are subject to audit at the discretion of the Authority. The Authority will terminate payments if the provider fails to abide by or violates the terms of their signed MOU. A provider may request a contested case proceeding to challenge a termination.

History

Statutory/Other Authority: ORS 410.070, 413.042 & 410.120
Statutes/Other Implemented: ORS 410.070, 414.033 & OL 2021 ch. 595
DMAP 41-2025, amend filed 04/29/2025, effective 05/01/2025
DMAP 33-2025, amend filed 03/21/2025, effective 03/23/2025
DMAP 123-2024, temporary amend filed 09/25/2024, effective 09/25/2024 through 03/23/2025
DMAP 52-2023, adopt filed 06/30/2023, effective 06/30/2023

Division 145 COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING

Or. Admin. R. 410-145-0000 Definitions

As used in this division unless the context requires otherwise:

(1) “Board of governors” means the governors of a cooperative program as described in OAR 410-145-0020.

(2) “Cooperative program” means a program among two or more health care providers for the purpose of providing heart and kidney transplant services including, but not limited to, the sharing, allocation and referral of physicians, patients, personnel, instructional programs, support services, facilities, medical diagnostic, laboratory or therapeutic services, equipment, devices or supplies, and other services traditionally offered by health care providers.

(3) “Director” means the Director of the Department of Human Services.

(4) “Health care provider” means a hospital, physician or entity, a significant part of whose activities consist of providing hospital or physician services in this state. For purposes of the immunities provided under ORS 442.700 to 442.760 and 646.740, “health care provider” includes any officer, director, trustee, employee, or agent of, or any entity under common ownership and control with, a health care provider.

(5) “Hospital” means a health care facility defined in ORS 442.015(14)(a) to (d) and licensed under 441.015–441.097 and includes community health programs established under 430.610–430.700. In other words, as used in this division the term “hospital” includes health care facilities licensed as hospitals, special inpatient care facilities, skilled and intermediate long-term care facilities, and ambulatory surgical centers. It also includes community mental health and developmental disabilities programs established under ORS 430.610 to 430.700. It does not include establishments furnishing primarily domiciliary care.

(6) “Order” means a decision issued by the director under OAR 410-145-0010 either approving or denying an application for a cooperative program and includes modification of an original order under 410-145-0040(3)(b) and orders under 410-145-0060(1) and (4).

(7) “Party to a cooperative agreement” or “party” means an entity that enters into the principal agreement to establish a cooperative program and applies for approval under this division and any other entity that, with the approval of the director, becomes a member of the cooperative program.

(8) “Physician” means a physician defined in ORS 677. 010(12) and licensed under ORS Chapter 677.

(9) “Urban area” means a Metropolitan Statistical Area as defined by the federal Bureau of the Census.

History

Statutory/Other Authority: ORS 413.042, 442.700 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0010 Application Procedures

(1) The Oregon Health Sciences University and one or more entities, each of which operates at least three hospitals in a single urban area in this state, may apply to the director for approval of a cooperative program.

(2) The application must include all of the following information, in the order specified:

(a) The names and addresses of each of the entities to be involved in the cooperative program, with a narrative describing how each entity meets the eligibility requirements set out in section (1) of this rule;

(b) A list of the names of all health care providers who propose to provide heart and kidney transplant services under the cooperative program, together with appropriate evidence of compliance with any licensing or certification requirements for those health care providers to practice in this state. The services to be provided by each provider and the location where these services are to be provided should be identified. In the case of employed physicians, the list and the information to be submitted may be limited to the employer or organizational unit of the employer;

(d) A description of proposed anticompetitive practices listed in paragraphs (A) through (E) of this subsection, any practices that the parties anticipate will have significant anticompetitive effects and a description of practices of the cooperative program affecting costs, prices, personnel positions, capital expenditures and allocation of resources. As provided in ORS 442.715(1), practices which may be authorized by an order issued under this rule include:

(A) Setting prices for heart and kidney transplants and all services directly related to heart and kidney transplants;

(B) Refusing to deal with competitors in the heart and kidney transplant market;

(D) Acquiring and maintaining a monopoly in heart and kidney transplant services; and

(E) Engaging in other activities that might give rise to liability under ORS 646.705–646.836 or federal antitrust laws.

(e) A list of the goals identified in paragraphs (A) through (H) of this subsection that the cooperative agreement expects to achieve, together with an explanation, including documentation as necessary, of the way in which such goals will be achieved and the anticipated time schedule for meeting these goals. The phrase “Reduction of, or protection against,” as used in paragraphs (A), (B) and (D) of this subsection, means that the applicants have two options for demonstrating accomplishment of these goals. The application may compare the projected results for the cooperative program to the existing situation, in which case a reduction in price, cost and duplication of resources compared to present conditions must be demonstrated. Alternatively, the application may compare the projected results for the cooperative program to the situation that would have existed if there were separate, competing transplant programs. In this latter case, the application must demonstrate that the proposed cooperative program will result in protection against the rising costs, rising prices and duplication of resources that might result if there were competing programs. As provided in ORS 442.705(2), goals which might be achieved through cooperative transplant programs include:

(A) Reduction of, or protection against, rising costs of heart and kidney transplant services;

(B) Reduction of, or protection against, rising prices for heart and kidney transplant services;

(D) Reduction of, or protection against, duplication of resources including, without limitation, expensive medical specialists, medical equipment and sites of service;

(E) Improvement or maintenance of efficiency in the delivery of heart and kidney transplant services;

(F) Improvement or maintenance of public access to heart and kidney transplant services;

(G) Increase in donations of organs for transplantation; and

(H) Improvement in the continuity of patient care.

(f) A description of the proposed places and manner of providing heart and kidney transplant services and services related to heart and kidney transplants under the cooperative program. This description should include a discussion of whether service sites have or will receive membership in the United Network for Organ Sharing (UNOS). If the cooperative program will not initially include both heart and kidney transplant services, the application shall identify which services will not initially be included, and will describe what will be done by the parties to work towards inclusion of such services in the future. The application must describe the ongoing efforts being made and any planned efforts for including both heart and kidney transplant services in the cooperative program;

(g) Projections of the number of heart transplants and the number of kidney transplants which the cooperative program expects to perform in each of its first three years of operation. These projections should be accompanied by a discussion of the methodology by which they were derived. A description of the expected service area(s) for the cooperative program’s services should also be included;

(h) If the application claims that the program will achieve the goal in paragraph (e)(G) of this section, or if the application projects an increase in the total number of heart or kidney transplants in the state, the application should discuss how donor organ availability would change as a result of the cooperative program’s operations, and explain the reasons why such changes are anticipated;

(i) If the applicants intend to demonstrate that the cooperative program will result in a reduction of costs, prices and duplication of resources compared to present conditions, the application must include a budget for the most recently completed fiscal year for each existing heart and kidney transplant program, as well as a proposed budget for operating the cooperative program for its first three years. The budget for the cooperative program must account for all applicable services listed in OAR 410-145-0000(2). Both the budgets for existing programs and the projected budget for the proposed cooperative program must include the following information:

(A) Gross revenues;

(B) Direct expenses, including a breakdown into salaries, payroll taxes and fringe benefits, any compensation to physicians to be paid by the program, supplies, bad debts, depreciation and interest, and other direct expenses;

(C) Indirect expenses, identified by categories which should include operation and maintenance of plant, housekeeping, billing, insurance, another indirect expenses;

(D) Deductions from revenue by component, including charity care;

(E) Net operating income (or loss) after the allocation of indirect expenses from non-revenue producing departments;

(F) Anticipated gross and net operating revenue per case for heart transplants and for kidney transplants;

(G) If either existing programs or the proposed cooperative programs charge or anticipate charging any flat fees for any transplant services, the amount of such fees (projected for the first three years of operation, in the case of the cooperative program);

(H) For the cooperative program only, any proposed capital expenditures; and

(I) Projected cost savings or cost increases to the health care system of the proposed cooperative program, compared to the costs of existing transplant services.

(j) If the applicants intend to demonstrate that the cooperative program will result in protection against rising costs, rising prices and duplication of resources compared to the situation that would have existed if there were separate, competing transplant programs, the application must include a proposed budget for operating the cooperative program for its first three years. This budget must account for all applicable services listed in OAR 410-145-0000(2) which will be delivered at a new transplant program site, and for all new services which will be delivered through the cooperative program at an existing site. The budget must also separately account for any existing services that will be included in or provide support to the cooperative program, but the application may provide a lesser level of detail for the budget information on existing services. The applicant must also provide a projected three year budget for new transplant service sites and associated support services, showing what would occur if the services proposed to be delivered by the cooperative program were to be delivered through separate, competing programs. Both the cooperative program budget and the hypothetical budget for a competing program must include the following information:

(A) Gross revenues;

(B) Direct expenses (for services provided through a new transplant program site or for new services at an existing site, include a breakdown into salaries, payroll taxes and fringe benefits, any compensation to physicians to be paid by the program, supplies, bad debts, depreciation and interest, and other direct expenses);

(C) Indirect expenses (for services provided through a new transplant program site or for new services at an existing site, identified by categories which should include operation and maintenance of plant, housekeeping, billing, insurance, and other indirect expenses);

(D) Deductions from revenue (for services provided through a new transplant program site or for new services at an existing site, deductions should be broken out by component, including charity care);

(E) Net operating income (or loss) after the allocation of indirect expenses from non-revenue producing departments;

(F) Anticipated gross and net operating revenue per case for heart transplants and for kidney transplants;

(G) If it is anticipated that either the cooperative or competitive program would charge any flat fees for any transplant services, a projection of such fees for the first three years of operation;

(H) For services provided through a new transplant site or for new services at an existing site, any proposed capital expenditures; and

(I) Projected cost savings or cost increases to the health care system of cooperative vs. competitive programs for transplant services.

(k) Satisfactory evidence of financial ability to deliver heart and kidney transplant services in accordance with the cooperative program. Such evidence shall include:

(A) Financial statements for each party to the application for each of the three previous years;

(B) The anticipated sources or reimbursement for heart transplants and sources of reimbursement for kidney transplants during the first three years of cooperative program operations. The application should discuss whether the cooperative program anticipates receiving Medicare certification for any proposed new heart and kidney transplant sites and, if so, when such certification is expected. The application should also discuss any existing or anticipated contractual agreements with third party payers regarding cooperative program services, and any anticipated modifications of existing contractual agreements concerning cooperative program services between parties to the cooperative agreement and third party payers.

(l) The agreement that establishes the cooperative program and policies that shall govern it.

(3) A joint application must be submitted on behalf of all parties to the proposed cooperative agreement. Four copies of the application shall be submitted to the Office of the Director, Oregon Health Authority, Human Services Building, Salem, Oregon 97310. The application must be accompanied by an application fee of $30,000. Checks should be made payable to the Oregon Health Authority.

(4) An application shall be considered filed as of the date that a complete application is received by the director. A complete application must meet all the requirements of sections (2) and (3) of this rule. Within 14 days of the receipt of an application, the director shall determine whether the application is complete, and notify the applicants if the application is complete or incomplete. If the application is incomplete, this notification shall include a detailed description of the additional information that is needed. The applicants may provide the additional information requested to make the application complete, or the applicants may elect to proceed with the review process without providing this information. The applicants should notify the director of their choice in this matter in writing within seven days of the director’s finding in regard to completeness. If the applicants elect to submit additional information, the notification to the director should include an acknowledgment by the applicants that the application as originally submitted was incomplete. If such notification and acknowledgment is not received by the director within seven days, it will be assumed that the applicants do no intend to submit additional information and wish to proceed immediately with the review. If the applicants elect to provide the additional information requested, a complete application shall not be considered to have been submitted until such information is received by the director. If the applicants elect not to provide such information, a complete application will be considered to have been submitted as of the date that the initial application was received by the director. In such an instance, however, the director may make negative findings concerning any areas that were found to be incomplete.

(5) The director shall review the application in accordance with the provisions of this rule and shall grant, deny or request modification of the application within 90 days of the date the application is filed. The director shall hold one or more public hearings on the application, which shall conclude no later than 80 days after the date the application is filed. Hearings shall be held in the applicants’ urban area. At least 14 days notice of any hearing will be provided. Notice of hearings shall be provided to the applicants; to all other hospitals located in the applicant’s urban area(s); to all wire services, daily newspapers and TV stations serving the state; and to any other persons who have requested notice of such hearings or who the director believes may have any interest in such hearings. The decision of the director shall be considered an order in a contested case for the purposes of ORS 183.310 to 183.550.

(6) The director shall approve an application made under this rule after:

(a) The applicants have demonstrated they will achieve at least six of the goals of subsection (2)(e) of this rule, including at least the goals listed in paragraphs (2)(e)(A) to (2)(e)(D); and

(b) The director has reviewed and approved the specifics of the anticompetitive activity expected to be conducted by the cooperative program.

(7) In evaluating the application, the director shall consider whether a cooperative program will contribute to or detract from achieving the goals listed under subsection (2)(e) of this rule. The director may weigh goals relating to circumstances that are likely to occur without the cooperative program, and relating to existing circumstances. The director may also consider whether any alternative arrangements would be less restrictive of completion while achieving the same goals.

(8) An order approving a cooperative program shall identify and define the limits of the permitted activities for the purposes of granting antitrust immunity under ORS 442.700 to 442.760.

(9) An order approving a cooperative program shall include:

(a) Approval of specific activities listed in subsection (2)(d) of this rule;

(b) Approval of activities the director anticipates will have substantial anticompetitive effects;

(d) The goals listed in subsection (2)(e) of this rule that the cooperative program is expected to achieve; and

(e) Approval of the cooperative program as described in the application and a finding that the cooperative program is in the public interest.

(10) An order denying the application for a cooperative program shall identify the findings of fact and reasons supporting denial.

(11) Either the director or all parties to the cooperative program may request an modification of an application made under this section. A request for a modification shall result in one extension of 30 days after submission of the modified application. The director shall issue an order under this section within 30 days after receipt of the modified application.

History

Statutory/Other Authority: ORS 413.042, 442.705, 442.710, 441.715 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0020 Board of Governors

(1) If the director issues an order approving an application for a cooperative program under OAR 410-145-0010, the director shall establish a board of governors to govern the cooperative program. The board of governors shall not constitute, for any purpose, a governmental agency.

(2) The board of governors shall consist of the president or other chief executive officer of each health care provider that is a party to the cooperative program agreement and the director or a designee of the director. The designee shall serve at the pleasure of the director. The designee shall not have any economic or other interest in any of the health care providers associated with the cooperative program.

(3) In governing the cooperative program, the board of governors shall develop policy and approve budgets for the implementation of the cooperative program.

(4) The director or designee of the director may reject any operating or capital budget of the cooperative program upon a finding by the director that the budget is not consistent with the goals listed in OAR 410-145-0010(2)(E) that the cooperative program is expected to achieve.

History

Statutory/Other Authority: ORS 413.042, 442.720 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0030 Annual Report

Not later than 60 days following each anniversary date of the director’s approval of a cooperative program, the board of governors of the cooperative program shall deliver four copies of an annual report to the director, accompanied by a review fee of $16,000. The report shall specifically describe:

(1) How heart and kidney transplant services and related services of the cooperative program are being provided in accordance with the order;

(2) Which of the goals identified in the order are being achieved and to what extent; and

(3) Any substantial changes in the cooperative program.

(4) If the cooperative program does not include both heart and kidney transplant services, the annual report will describe any efforts that have been made by the parties over the previous year to provide for inclusion of both heart and kidney transplants in the cooperative program, and will describe what the parties will do to work towards inclusion of such services in the future. The annual report must describe the ongoing efforts being made and any planned efforts for including both heart and kidney transplant services in the cooperative program.

History

Statutory/Other Authority: ORS 413.042, 442.725 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0040 Review and Evaluation of Annual Report

(1) The director shall review and evaluate the annual report delivered under OAR 410-145-0030. The director shall:

(a) Determine the extent to which the cooperative program is achieving the goals identified in the order;

(b) Review the activities being conducted to achieve the goals; and

(2) If the director determines that additional information is needed for the review described in section (1) of this rule, the director may order the board of governors to provide the information within a specified time. Such an order shall be issued no later than 14 days after receipt of the cooperative program’s annual report.

(3) Within 60 days after receiving the annual report or any additional information ordered under section (2) of this rule, the director shall:

(a) Approve the report if the director determines that the cooperative program is operating in accordance with the order and that the goals identified in the order are being adequately achieved by the cooperative program;

(b) Modify the order as appropriate to adjust to changes in the cooperative program approved by the director and approve the report as provided in subsection (a) of this section;

(c) Order the board of governors to make remedial changes in anticompetitive activities not in compliance with the order and request the board of governors to report on progress not later than a deadline specified by the director;

(d) Revoke approval of the cooperative program; or

(e) Take any of the action set forth in OAR 410-145-0060.

History

Statutory/Other Authority: ORS 413.042, 442.730 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0050 Complaint Procedure

(1) Any person may file a complaint with the director requesting that a specific decision or action of a cooperative program supervised by the director be reversed or modified, or that approval for all or part of the activities permitted by the order be suspended or terminated. The complaint shall allege the reasons for the requested action and shall include any evidence relating to the complaint.

(2) The director on the director’s own initiative may at any time request information from the board to governors concerning the activities of the cooperative program to determine whether the cooperative program is in compliance with the order.

History

Statutory/Other Authority: ORS 413.042, 442.735 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0060 Action on Complaints

(1) During the review of the annual report described in OAR 410-145-0040, after receiving a complaint under 410-145-0050, or on the director’s own in initiative, the director may take one or more of the following actions:

(a) If the director determines that a particular decision or action is not in accordance with the order, or that the parties are engaging in anticompetitive activity not permitted by the order, the director may direct the board of governors to identify and implement corrective action to insure compliance with the order or may modify the order.

(b) If the director determines that the coopera-tive program is engaging in unlawful activity not permitted by the order or is not complying with the directive given under subsection (a) of this section, the director may serve on the cooperative program a proposed order directing the cooperative program to:

(A) Conform with the directive under sub-section (a) of this section; or

(B) Cease and desist from engaging in the activity.

(2) The cooperative program shall have up to 30 days to comply with a proposed order under subsection (1)(b) of this rule, counted from the order’s date of issuance, unless the board of governors demonstrates to the director’s satisfaction that additional time is need for compliance.

(3) If the director determines that the participants in the cooperative program are in substantial noncompliance with the cease and desist directive, the director may seek an appropriate injunction in the circuit courts of Marion or Multnomah Counties.

(4) If the director determines that a sufficient number of goals set forth in OAR 410-145-0010(2)(e) are not being achieved or that the cooperative program is engaging in activity not permitted by the order, the director may suspend or terminate approval for all or part of the activities approved and permitted by the order.

(5) A proposed order to be entered under subsection (1)(b) or section (4) of this rule may be served upon the cooperative program without prior notice. The cooperative program may contest the proposed order by filing a written request for a contested case hearing with the director not later than 20 days following the date of the proposed order. The proposed order shall become final if no request for a hearing is received. Unless inconsis-tent with this section, the provisions of ORS 183.310–183.550, as applicable, shall govern the hearing procedure and any judicial review.

(6) The only effect of an order suspending or terminating approval under ORS 442.700–442.760 shall be to withdraw the immunities granted under 442.715(3) for anticompetitive activity permitted by the order and taken after the effective date of the order.

History

Statutory/Other Authority: ORS 442.740 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0070 Confidentiality of Information

(1) If parties to a cooperative program agreement provide the director with written or oral information that is confidential or otherwise protected from disclosure under Oregon law, the disclosures shall not be considered a waiver of any right to protect the information from disclosure in other proceedings.

(2) The parties to a cooperative agreement shall specifically identify to the director any information that meets the requirements of section (1) of this rule, and the director shall considered only information that has been so identified by the parties to be confidential. The director will make the decision as to whether such information is in fact protected from disclosure under Oregon law. The director shall inform the party who submitted the information of any decisions regarding its confidentiality. Information which has been found to be subject to disclosure under Oregon law may be released by the director to any requesting persons subject to the provisions of ORS 192.410–192.505.

History

Statutory/Other Authority: ORS 413.042, 442.750 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Or. Admin. R. 410-145-0080 Reconsideration and Judicial Review

(1) Orders, modifications of orders, findings and directives issued under OAR 410-145-0010, 410-145-0040(3), or 410-145-0060(1)(a) are subject to reconsideration and stay under the procedures provided in 137-003-0080 through 137-003-0092.

(2) Notwithstanding the provisions of ORS 183.310(6) and 183.480, only a party to a cooperative program agreement or the director shall be entitled to a contested case hearing, reconsideration, or judicial review of an order issued pursuant to 442.700 to 442.760.

(3) The director may recover any expenses incurred in the conduct of any hearing under this rule, including hearing officer and court reporter fees and the director’s legal expenses, through an assessment on other parties to the hearing.

History

Statutory/Other Authority: ORS 413.042, 442.710, 442.730, 442.740 & 442.755
Statutes/Other Implemented: ORS 413.042
HR 16-1994, f. & cert. ef. 3-31-94

Division 146 AMERICAN INDIAN/ALASKA NATIVE

Or. Admin. R. 410-146-0000 Foreword

(1) The Health Systems Division (Division) American Indian/Alaska Native (AI/AN) Oregon Administrative Rules are designed to assist the following providers to prepare claims for services provided to clients with Medical Assistance Program coverage:

(a) Indian Health Service (IHS) facilities; and

(b) Tribal 638 facilities, defined as Tribally-operated health care clinics owned or operated by a Tribe or Tribal organization with funding authorized by Title I or Title V of the Indian Self-Determination and Education Assistance Act (Public Law 93-638, as amended), and recognized by the Centers for Medicare and Medicaid Services (CMS) under the 1996 Memorandum of Agreement (MOA);

(2) Indian Health Care Providers (IHCP) not designated an IHS or Tribal 638 facility should refer to Oregon Health Plan (OHP) General Rules (OAR 410 division 120) and other applicable program-specific rules to enroll and operate as any other provider type recognized under the state plan.

(3) CMS does not recognize Urban Indian Health Program (UIHP) clinics as eligible for reimbursement of services under the MOA. UIHP Clinics should refer to:

(a) Federally Qualified Health Centers (FQHC) and Rural Health Clinics administrative Rules (OAR 410 division 147) to enroll as a FQHC if the clinic is an urban Indian organization under the Indian Health Care Improvement Act, Public Law 94-437; or

(b) OHP General Rules (OAR 410 division 120) and other applicable program-specific rules to enroll and operate as any other provider type recognized under the state plan.

(4) The AI/AN administrative rules include important information about general program policy, provider enrollment, maintenance of financial records, special programs, and billing. Unless specifically directed by the AI/AN rules, do not use other Division administrative rules to determine appropriate action.

(5) OHP-enrolled IHCP must use the OHP General Rules (OAR 410 division 120) and the OHP Administrative Rules (OAR 410 Division 141) as directed in the AI/AN rules and in conjunction with applicable program-specific rules including the AI/AN administrative rules.

(6) The Health Evidence Review Commission's Prioritized List of Health Services defines the Division’s Medicaid-covered services. For more information, refer to the OHP Administrative Rules (OAR 410-141-0520).

History

Statutory/Other Authority: ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0020 Memorandum of Agreement Reimbursement Methodology

(1) In 1996, a Memorandum of Agreement (MOA) between the Centers for Medicare and Medicaid Services (CMS) and the Indian Health Service (IHS) established the roles and responsibilities of CMS and IHS regarding the Division’s American Indian/Alaska Native (AI/AN) Program individuals. The MOA addresses payment for Medicaid services provided to AI/AN individuals on and after July 11, 1996, through health care facilities owned and operated by AI/AN tribes and tribal organizations, which are funded through Title I or V of the Indian Self-Determination and Education Assistance Act (Public Law 93-638).

(2) The IHS and CMS, pursuant to an agreement with the Office of Management and Budget (OMB), developed an all-inclusive rate to be used for billing directly to and reimbursement by Medicaid. This rate is sometimes referred to as the "OMB," "IHS," "All-Inclusive" (AIR), "encounter," or "MOA" rate and is referenced throughout these rules as the "IHS rate." The IHS rate is updated and published in the Federal Register each fall:

(a) The rate is retroactive to the first of the year;

(b) The Division automatically processes a retroactive billing adjustment each year to ensure payment of the updated rate.

(3) IHS direct health care service facilities established, operated, and funded by IHS shall enroll as an IHCP and receive the IHS rate.

(4) Under the MOA, Tribal 638 health care facilities may choose to be designated a certain type of provider or facility for enrollment with OHP. The designation determines how the Division pays for the Medicaid services provided by that provider or facility. Under the MOA, a Tribal 638 health care facility may do one of the following:

(a) Operate as a Tribal 638 health care facility. The health center would enroll as an IHCP and choose reimbursement for services at either:

(A) The IHS rate; or

(B) A cost-based rate according to the Prospective Payment System (PPS). Refer to OAR 410-147-0360, Encounter Rate Determinations, 410-147-0440, Medicare Economic Index (MEI), 410-147-0480, Cost Statement (OHP 3027) Instructions, and OAR 410-147-0500, Total Encounters for Cost Reports; or

(b) If it so qualifies, operate as any other provider type recognized under the State Plan and receive that respective reimbursement methodology.

(5) AI/AN and the Division’s FQHC and RHC program providers may be eligible to receive the supplemental/wraparound payment for services furnished to clients enrolled with a Prepaid Health Plan (PHP). Refer to AI/AN OAR 410-146-0420 and FQHC/ RHC administrative rules OAR chapter 410, division 147.

(6) IHCPs may be eligible for an administrative match contract with the Division. IHCPs may not participate in the Medicaid Administrative Claiming (MAC) program if they:

(a) Receive reimbursement for services according to the cost-based PPS rate methodology; or

(b) Receive financial compensation for Out-Stationed Outreach Worker (OSOW) activities.

(7) An IHCP that chooses to participate in the Patient Centered Primary Care Home program (PCPCH) must meet the requirements and adhere to rules outlined in OAR 409-055-0000 through 409-055-0080 Health Policy and Analytics and OAR 410-141-0860 Oregon Health Plan Primary Care Manager and Patient Centered Primary Care Home Provider Qualification and Enrollment. The PCPCH program is outside the Prospective Payment System and the IHS/MOA rate. IHCPs who choose to participate and meet all PCPCH related requirements shall receive a separate reimbursement per the per member per month (PMPM) payment established by OAR 410-141-0860.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 14-2012, f. & cert. ef. 3-22-12
DMAP 28-2011, f. 9-30-11, cert. ef. 10-1-11
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0021 American Indian/Alaska Native (AI/AN) Provider Enrollment

(1) This rule outlines the Division requirements for Indian Health Service (IHS) and Tribal 638 clinics to enroll as American Indian/Alaska Native (AI/AN) providers (refer to OAR 410-120-1260, Provider Enrollment).

(2) An IHS or Tribal 638 clinic that operates a retail pharmacy provides durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) or provides targeted case management (TCM) services must enroll separately as a pharmacy, DMEPOS, or TCM provider. For specific information, refer to OAR chapter 410, division 121, Pharmaceutical Services program; OAR chapter 410, division 122, DMEPOS program; and OAR chapter 410, division 138, TCM program.

(3) To enroll with the Division as an IHCP, a health center must be one of the following:

(a) An IHS direct health care services facility established, operated, and funded by IHS; or

(b) A Tribally-owned and operated facility funded by Title I or V of the Indian Self Determination and Education Assistance Act (Public Law 93-638) and is referenced throughout these rules as a “Tribal 638” provider:

(A) A Tribal 638 facility that has administrative control, operation, and funding for health programs transferred to AI/AN tribal governments under a Title I contract with IHS;

(B) A Tribal 638 facility that assumes autonomy for the provision of the tribe’s own health care services under a Title V compact with IHS.

(4) Eligible IHS and Tribal 638 providers who want to enroll with the Division as an IHCP must submit the following information:

(a) Completed Oregon Health Authority (Authority) provider enrollment forms with attachments;

(b) A Tribal facility must submit documentation verifying they are a 638 provider:

(A) A letter from IHS, applicable-Area Office or Central Office, indicating that the facility (identified by name and address) is a 638 facility;

(B) A written assurance from the Tribe that the facility (identified by name and site address) is owned or operated by the Tribe or a Tribal organization with funding directly obtained under a 638 contract or compact. A copy of the relevant provision of the Tribe’s current 638 contract or compact must accompany the written assurance;

(c) A copy of the clinic’s Division certification for a program of behavioral health services if someone other than a licensed psychiatrist, licensed clinical psychologist, licensed clinical social worker, psychiatric nurse practitioner, licensed professional counselor, or licensed marriage and family therapist is providing behavioral health services;

(d) A copy of the clinic’s Division letter or licensure of approval if providing Substance Use Disorder (SUD) services;

(e) A list of all Prepaid Health Plan (PHP) contracts;

(f) A list of all practitioners contracted with or employed by the IHS or Tribal 638 facility including names, legacy Division provider numbers, National Provider Identifier (NPI) numbers, and associated taxonomy codes; and

(g) A list of all clinics affiliated or owned by the IHS or Tribal 638 facility including business names, legacy Division provider numbers, National Provider Numbers (NPI) and associated taxonomy codes.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 37-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 46-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 59-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-146-0040 ICD-10-CM Diagnosis Codes and CPT/HCPCs Procedure Codes

(1) The Division requires diagnosis codes on all claims including those submitted by independent laboratories and portable radiology and including nuclear medicine and diagnostic ultrasound providers. A clinic must always provide the client's diagnosis to ancillary service providers when prescribing services, equipment, and supplies.

(2) The appropriate ICD-10-CM code must be used to identify:

(a) Diagnoses;

(b) Symptoms;

(d) Problems;

(e) Complaints; or

(f) Other reasons for the encounter/visit.

(3) Clinics must list the principal diagnosis in the first position on the claim. Clinics must use the principal diagnosis code for the diagnosis, condition, problem, or other reason for an encounter/visit shown in the medical record to be chiefly responsible for the services provided. Clinics may list up to three additional diagnosis codes on the claim for documented conditions that coexist at the time of the encounter/visit and require or affect client care, treatment, or management.

(4) Clinics must list the diagnosis codes using the highest degree of specificity available in the ICD-10-CM. The Division considers a diagnosis code invalid if it has not been coded to its highest specificity.

(5) The Division requires providers to use the standardized code sets required by the Health Insurance Portability and Accountability Act (HIPAA) and adopted by CMS. Unless otherwise directed in rule, providers must accurately code claims according to the national standards in effect for the date the service was provided:

(a) For dental services, use codes that are in effect for the date the services was provided that are found in Dental Procedures and Nomenclature as maintained and distributed by the American Dental Association;

(b) For health care services, use the combination of Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes in effect for the date the services was provided. These services include, but are not limited to, the following:

(A) Physician services;

(B) Physical and occupational therapy services;

(D) Clinical laboratory tests;

(E) Other medical diagnostic procedures;

(F) Hearing and vision services.

(6) The Division maintains unique coding and claim submission requirements for Administrative Exams and Death with Dignity services. Refer to OAR 410 division 150, Administrative Examination and Billing Services, and OAR 410-130-0670, Death with Dignity Services for specific requirements.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 41-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0060 Prior Authorization

(1) Some covered services or items require prior authorization (PA) by the Division before the service may be provided or before payment will be made. Refer to Oregon Administrative Rule (OAR) 410-120-1320 Authorization of Payment.

(2) Most Oregon Health Plan (OHP) clients have prepaid health services contracted by the Oregon Health Authority (Authority) through enrollment in a PHP. Refer to OAR 410-120-1140 Verification of Eligibility.

(3) An OHP client who is an American Indian or Alaska Native (AI/AN) with proof of Indian heritage is exempt from mandatory enrollment in a PHP and can request disenrollment from a PHP if automatically enrolled. An AI/AN OHP client may choose to remain in the Medicaid fee-for-service (FFS) delivery system for physical, dental, and behavioral health care, including SUD health care and receive services from an Indian Health Service facility, tribal health clinic or program or urban clinic. Refer to OAR 410-141-0060.

(4) If a client is enrolled in a PHP there may be PA requirements for some services that are provided through the PHP. The IHCP shall contact the PHP prior to providing services to any:

(a) Non-AI/AN OHP clients enrolled in a PHP and with whom the IHCP has a contract to comply with the PHP’s PA requirements or other policies necessary for reimbursement from the PHP. The IHCP must contact the client's PHP for specific instructions;

(b) AI/AN OHP client enrolled in a PHP with whom the IHCP does not have a contract to comply with PA requirements in these rules, the General Rules, and applicable Division program rules.

(5) If a client receives services on a FFS basis or is an AI/AN PHP-enrolled client with whom the IHCP does not have a contract and plans to bill the Division directly on an FFS basis, a PA may be required from the Division for certain services. An IHCP assumes full financial risk in providing services to a client prior to receiving authorization or in providing services that are not in compliance with Oregon Administrative Rules.

(6) If the service or item is subject to PA, the IHCP must follow and comply with PA requirements in these rules, the General Rules, and applicable program rules, including but not limited to:

(a) The service is adequately documented (see OAR 410-120-1360, Requirements for Financial, Clinical and Other Records). Providers must maintain documentation in the provider's files to adequately determine the type, medical appropriateness, or quantity of services provided;

(b) The services provided are consistent with the information submitted when authorization was requested;

(d) The services are provided within the timeframe specified on the authorization of payment document.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0075 Client Copayments

(1) AI/AN clients who are members of a federally recognized Indian Tribe or Tribal Organization and receive Medicaid-covered services rendered through an IHCP are exempt from copayments. Refer to OAR 410-120-1230 Client Copayment.

(2) IHCPs may not charge copayments to eligible non-AI/AN Division clients receiving care at their facility.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 89-2002, f. 12-24-02, cert. ef. 1-1-03

Or. Admin. R. 410-146-0080 Professional Ambulatory Services

(1) Professional Ambulatory services provided by IHCP include Medical, Diagnostic, Screening, Dental, Vision, Physical Therapy, Occupational Therapy, Podiatry, Behavioral Health, Substance Use Disorder, Maternity Case Management, Speech, Hearing, and Home Health services.

(2) Providers must use the following guidelines in conjunction with all individual program-specific Division administrative rules to determine service coverage and limitations for OHP clients according to their benefit packages:

(a) American Indian/Alaska Native (AI/AN) Services administrative rules (OAR 410 division 146),

(b) General Rules (OAR 410 division 120);

(d) The Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (List).

(3) IHS and Tribal 638 facilities may be reimbursed for covered professional services provided within the scope of the clinic and within the individual practitioner’s scope of license or certification. See also AI/AN OAR 410-146-0085.

(4) The date of service determines the appropriate version of the AI/AN Services Rules, General Rules, and the HERC Prioritized List that IHCPs should use to determine coverage.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 16-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0085 Encounter and Recognized Practitioners

Encounter and Recognized Practitioners

(1) The Division shall reimburse enrolled AI/AN providers as follows:

(a) For services, items, and supplies that meet the criteria of a valid encounter in sections (5) through (7) of this rule;

(b) Reimbursement is limited to the Division’s Medicaid-covered services according to a client’s OHP benefit package. These services may include any services included in the State Plan under Title XIX or Title XXI of the Social Security Act and provided pursuant to the determinations, conditions, and requirements of the Prioritized List of Health Services found in the Health Evidence Review Commission’s Prioritized List of Health Services (see OAR 410-141-0520).

(2) IHCPs reimbursed according to a cost-based rate under the Prospective Payment System (PPS) shall use OAR 410-147-0120, Encounter and Recognized Practitioners, in the Division’s FQHC and RHC program.

(3) IHCPs reimbursed according to the IHS rate are subject to the requirements of this rule.

(4) Services provided to Citizenship Waived Medical (CWM) and Qualified Medicare Beneficiary (QMB) only clients are not billed according to encounter criteria and not reimbursed at the IHS encounter rate (refer to OAR 410-120-1210, Medical Assistance Benefit Packages and Delivery System).

(5) For the provision of services defined in Titles XIX and XXI and provided through an IHS or Tribal 638 facility, an “encounter” is defined as a face-to-face, telephone contact, or a prescription fill as defined in OAR 410-146-0085(8) between a health care professional and an eligible OHP client within a 24-hour period ending at midnight, as documented in the client’s medical record. Section (7) of this rule outlines limitations for telephone contacts that qualify as encounters. For purposes of this rule, face-to-face “encounter” includes services provided via a synchronous two-way audiovisual link between a patient and a provider per 410-130-0610.

(6) An encounter includes all services, items, and supplies provided to a client during the course of an office visit and “incident-to” services (except as excluded in section (17) of this rule). The following services are inclusive of the visit with the core provider meeting the criteria of a reimbursable valid encounter and are not reimbursed separately:

(a) Drugs or medication treatments provided during the clinic visit, with the exception of contraception supplies and medications as costs for these items are excluded from the IHS encounter rate calculation (refer to OAR 410-146-0200, Pharmacy);

(b) Medical supplies, equipment, or other disposable products (e.g. gauze, Band-Aids, wrist brace); and

(7) An IHS or Tribal 638 Pharmacy encounter is a separate encounter and not made in conjunction with a medical, behavioral health, substance use disorder, or dental visit or with any other non-pharmacy visit related to a covered benefit.

(8) A single pharmacy encounter includes one prescription dispensed by one IHS or Tribal 638 Pharmacy to a Medicaid-eligible individual in a single 24-hour period ending at midnight. There is no limit on the number of encounters that may occur in the 24-hour period. The encounter rate is inclusive of dispensing services.

(9) Telephone encounters qualify as a valid encounter for services provided in accordance with OAR 410-130-0595, Maternity Case Management; OAR 410-146-0200, Tribal Pharmacy; and OAR 410-130-0190, Tobacco Cessation (OAR 410-120-1200). Except as set forth below, Providers may not make telephone contacts at the exclusion of face-to-face visits.

(a) Telephone encounters must include all the same components of the service as if provided face-to-face.

(b) During a state of emergency of an epidemic outbreak of an infectious disease impacting the safety of public health, in accordance with the Health Evidence Review Commission’s Prioritized List, guideline notes, and OAR 410-130-0610 (for dates of service on or before December 31, 2020) and OAR 410-120-1990 (for dates of service on or after January 1, 2021), telephonic evaluation management services, assessment and management services, and psychotherapy are appropriate to ensure access to care while avoiding and preventing unnecessary potential infectious exposure, and may be made in place of a face-to-face visit.

(10) The following services may be Medicaid-covered services according to an OHP client’s benefit package as a stand-alone service; however, when furnished as a stand-alone service, they are not reimbursable:

(a) Case management services for coordinating care for a client;

(b) Sign language and oral interpreter services;

(c) Supportive rehabilitation services including, but not limited to, environmental intervention, supported employment, or skills training and activity therapy to promote community integration and job readiness.

(11) IHCPs may provide certain services, items, and supplies that are prohibited from being billed under the health centers provider enrollment and that require separate enrollment (see OAR 410-146-0021, AI/AN Provider Enrollment). These services include:

(a) Durable medical equipment, prosthetics, orthotics, or medical supplies (DMEPOS) (e.g., diabetic supplies) not generally provided during the course of a clinic visit (refer to OAR chapter 410, division 122, DMEPOS);

(b) Prescription pharmaceuticals and biologicals not generally provided during the clinic visit that are dispensed by an IHS or Tribal 638 Pharmacy may be billed to and shall be reimbursed by the Division through the pharmacy program (refer to OAR chapter 410, division 121, Pharmaceutical Services) or at the All-Inclusive Rate (AIR) as established annually by the Indian Health Service (IHS); and

(12) Client contact with more than one health professional for the same diagnosis or multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit. For exceptions to this rule, see OAR 410-146-0086 for reporting multiple encounters.

(13) For claims that require a procedure and diagnosis code, the provider must bill as instructed in the appropriate Division program rules and must use the appropriate HIPAA procedure Code Set established according to 45 CFR 162.1000 to 162.1011, which best describes the specific service or item provided (refer to OARs 410-120-1280, Billing and OAR 410-146-0040, ICD-10-CM Diagnosis Codes and CPT/HCPCs Procedure Codes).

(14) Services furnished by AI/AN enrolled providers that may meet the criteria of a valid encounter (refer to individual program administrative rules for service limitations):

(a) Medical (OAR chapter 410, division 130);

(b) The Division covers reasonable services for diagnosing conditions, including the initial diagnosis of a condition that is below the funding line on the HERC’s Prioritized List of Health Services. Once a diagnosis is established for a service, treatment, or item that falls below the funding line, the Division may l not cover any other services related to the diagnosis;

(d) Dental (OAR 410-146-0380 and OAR chapter 410, division 123);

(e) Vision (OAR chapter 410, division 140);

(f) Physical Therapy (OAR chapter 410, division 131);

(g) Occupational Therapy (OAR chapter 410, division 131);

(h) Podiatry (OAR chapter 410, division 130);

(i) Behavioral health OAR chapter 309;

(j) Substance Use Disorder services (OAR 410-146-0021) require a letter or licensure of approval by the Division;

(k) Maternity Case Management (OAR 410-146-0120);

(L) Speech (OAR 410 Division 129);

(m) Hearing (OAR 410 Division 129);

(n) The Division considers a home visit for assessment, diagnosis, treatment, or maternity case management (MCM) as an encounter. The Division does not consider home visits for MCM as home health services;

(o) Professional services provided in a hospital setting;

(p) Prescriptions dispensed by an IHS or Tribal 638 Pharmacy constitute a separate encounter reimbursed at the annually published IHS All-Inclusive-Rate;

(q) Other Title XIX or XXI services as allowed under Oregon's Medicaid and CHIP State Plan Amendments, Oregon’s approved 1115 Medicaid Demonstration, and the Division’s administrative rules.

(15) The following practitioners are recognized by the Division:

(a) Doctors of medicine, osteopathy, and naturopathy;

(b) Licensed physician associates;

(d) Registered nurses may accept and implement orders within the scope of their license for client care and treatment under the supervision of a licensed health care professional recognized by the Division in this section and who is authorized to independently diagnose and treat according to appropriate State of Oregon’s Board of Nursing OARs;

(e) Nurse midwives;

(f) Dentists;

(g) Dental hygienists who hold a Limited Access Permit (LAP) may provide dental hygiene services without the supervision of a dentist in certain settings. For more information, refer to the section on Limited Access Permits in ORS 680.200 and the appropriate Oregon Board of Dentistry OARs;

(h) Pharmacists;

(i) Psychiatrists;

(j) Licensed Clinical Social Workers;

(k) Clinical psychologists;

(L) Acupuncturists, refer to OAR chapter 410, division 130 for service coverage and limitations;

(m) Licensed professional counselor;

(n) Licensed marriage and family therapist; and

(o) Other health care professionals providing services within their scope of practice and working under the supervision requirements of:

(A) Their individual provider certification or license; or

(B) A clinic’s behavioral health certification or SUD program approval or licensure by the Division.

(16) Encounters with a registered professional nurse or a licensed practical nurse and related medical supplies, including drugs and biologicals, furnished on a part-time or intermittent basis to home-bound AI/AN clients residing on tribal land and any other ambulatory services covered by the Division are also reimbursable as permitted within the clinic's scope of services.

(17) The Division shall reimburse the following services fee-for-service outside of the IHS all-inclusive encounter rate and according to the physician fee schedule:

(a) Laboratory and radiology services;

(b) Contraception supplies and medications;

(d) Death with Dignity services (refer to OAR 410-130-0670); and

(e) Comprehensive environmental lead investigation (refer to OAR 410-130-0245, Early and Periodic Screening, Diagnostic and Treatment program).

(18) Federal law requires that state Medicaid agencies take all reasonable measures to ensure that in most instances the Division will be the payer of last resort. Providers must make reasonable efforts to obtain payment first from other resources before billing the Division (refer to OAR 410-120-1140, Verification of Eligibility).

(19) When a provider receives a payment from any source prior to the submission of a claim to the Division, the amount of the payment must be shown as a credit on the claim in the appropriate field (refer to OARs 410-120-1280, Billing and 410-120-1340, Payment).

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 27-2025, minor correction filed 01/22/2025, effective 01/22/2025
DMAP 18-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 46-2020, amend filed 09/11/2020, effective 09/15/2020
DMAP 11-2020, temporary amend filed 03/20/2020, effective 03/20/2020 through 09/15/2020
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 37-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 46-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 21-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
Renumbered from 410-146-0080, DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 16-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0086 Multiple Encounters

(1) An “encounter” has the meaning given that term in OAR 410-146-0085.

(2) The following services may be considered as multiple encounters when two or more service encounters are provided on the same date of service with distinctly different diagnoses:

(a) Medical (section (3) of this rule and OAR chapter 410, division 130);

(b) Dental (OAR 410-146-0380 and chapter 410, division 123);

(c) Behavioral Health. If a client is also seen for a medical office visit and receives a behavioral health diagnosis, then the client contacts are a single encounter.

(d) Substance Use Disorder. If a client is also seen for a medical office visit and receives an addiction diagnosis, then the client’s contacts are a single encounter (refer to the Division for the appropriate OARs);

(e) Ophthalmology. Fitting and dispensing of eyeglasses are included in the encounter when the practitioner performs a vision examination. (OAR chapter 410, division 140);

(f) Maternity Case Management (MCM) (OAR 410-146-0120);

(g) Physical or occupational therapy (PT/OT). If this service is also performed on the same date of service as the medical encounter that determined the need for PT/OT (initial referral), then it is considered a single encounter (OAR chapter 410, division 131);

(h) Immunizations. If no other medical office visit occurs on the same date of service; and

(i) Tobacco cessation. If no other medical, dental, behavioral health, or SUD service encounter occurs on the same date of service (OAR 410-130-0190).

(j) One or more prescriptions for pharmaceuticals and biologicals not generally provided during the clinic visit that are dispensed by an IHS or Tribal 638 Pharmacy to the same individual constitute multiple encounters when delivered in a single 24-hour period ending at midnight.

(3) Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and that share the same or like diagnoses constitute a single encounter, except when one of the following conditions exist:

(a) After the first medical service encounter, the patient suffers a distinctly different illness or injury requiring additional diagnosis or treatment. More than one office visit with a medical professional within a 24-hour period and receiving distinctly different diagnoses may be reported as two encounters. This does not imply that if a client is seen at a single office visit with multiple problems that the provider can bill for multiple encounters;

(b) The patient has two or more encounters as described in section (2) of this rule.

(4) A behavioral health encounter and a SUD encounter provided to the same client on the same date of service shall only count as multiple encounters when provided by two separate health professionals and each encounter has a distinctly different diagnosis.

(5) Similar services even when provided by two different health care practitioners are considered a single encounter and not multiple encounters. Services that would not be considered multiple encounters provided on the same date of service include, but are not limited to:

(a) A well child check and an immunization;

(b) A well child check and fluoride varnish application in a medical setting;

(d) A prenatal visit and a delivery procedure;

(e) A cesarean delivery and surgical assist; and

(f) Any time a client receives only a partial service with one provider and partial service from another provider.

(6) A clinic may not develop clinic procedures that routinely involve multiple encounters for a single date of service.

(7) Clinics may not “unbundle” services that are normally rendered during a single visit for the purpose of generating multiple encounters:

(a) Clinics may not ask the patient to make repeated or multiple visits to complete what is considered a reasonable and typical office visit, unless it is medically necessary to do so;

(b) Medical necessity must be clearly documented in the patient’s record.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 37-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
Renumbered from 410-146-0080, DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 16-2005, f. 3-11-05, cert. ef. 4-1-05
OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0100 Vaccines for Children

(1) The Vaccines for Children (VFC) program supplies federally purchased free vaccines for immunizing eligible clients ages 0 through 18 at no cost to participating health care providers. For more information on how to enroll in the VFC program, contact the Oregon Health Authority (Authority) Immunization program. Refer to the AI/AN Supplemental Information for instructions and OAR 410-130-0255(4) VFC program.

(2) The Division shall reimburse for the administration of vaccines to eligible clients according to the IHCP’s IHS or cost-based rate.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 61-2005, f. 11-29-05, cert. ef. 12-1-05
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0120 Maternity Case Management Services

(1) The Division shall reimburse IHCP for MCM services according to their encounter rate.

(2) MCM service is optional coverage for Prepaid Health Plans (PHPs). Before providing MCM services to clients enrolled in a PHP, determine if the PHP covers MCM services:

(a) If the PHP does not cover MCM services, the provider may bill the Division directly per the clinic’s encounter rate. Prior authorization is not required if the PHP does not provide coverage for MCM services;

(b) If the PHP does cover MCM services, and services were furnished to a:

(A) Non-AI/AN client, the provider needs to request the necessary authorizations from the PHP;

(B) AI/AN client enrolled with a PHP with which the IHCP does not have an agreement, the IHCP may bill the Division directly.

(3) Clients’ records must clearly document all MCM services provided including all mandatory topics. For specific requirements, refer to the Medical-Surgical Services program OAR 410-130-0595, Maternity Case Management.

(4) The primary purpose of the MCM program is to optimize pregnancy outcomes including the reduction of low birth weight babies. MCM services are intended to target pregnant women early during the prenatal period and can only be initiated when the client is pregnant:

(a) MCM services may not be initiated the day of delivery, during postpartum, or for newborn evaluation;

(b) Clients are not eligible for MCM services if the provider has not completed the MCM initial evaluation prior to the day of delivery;

(5) Multiple MCM contacts in a single day do not qualify as multiple encounters.

(6) A medical/prenatal visit encounter and an MCM encounter may qualify as two separate encounters when furnished on the same day only when the MCM service is:

(a) The initial evaluation to receive MCM services; or

(b) A nutritional counseling MCM service provided after the initial evaluation visit.

(7) MCM Services limitations:

(a) The Division shall reimburse the initial evaluation one time per pregnancy per provider;

(b) The Division shall reimburse nutritional counseling one time per pregnancy if a client meets the criteria in OAR 410-130-0595(14); and

(c) The Division shall reimburse a maximum of ten MCM services/visits in addition to subsections (a) and (b) above, providing visits/services are furnished in compliance with OAR 410-130-0595.

(8) Case management services may not duplicate services for case management activities or direct services provided under the State Plan or OHP through fee for service, managed care, or other contractual arrangement that meet the same need for the same client at the same point in time. This includes the Division’s Maternity Case Management program (OAR chapter 410, division 130) and any Targeted Case Management (TCM) program outlined in OAR chapter 410, division 138.

(9) Community health representatives may be eligible to provide specific MCM services, with the exclusion of the initial assessment (G9001), while working under the supervision of a licensed health care practitioner listed in OAR 410-130-0595(7)(a).

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 37-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0130 Modifiers

(1) The Division uses HIPAA compliant modifiers for many services.

(2) The following services require the use of a modifier for all services for all procedures:

(a) Family planning service -- FP, refer to OAR 410-130-0585 Family Planning Services;

(b) Vaccine for children -- SL or 26, refer to OAR 410-130-0255.

(3) When billing for services that are reimbursed outside an IHCP’s cost-based or IHS rate, a clinic must use the required modifier listed in the individual program-specific administrative rules.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03
OMAP 59-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-146-0160 Administrative Medical Examinations and Reports

(1) The Division may not reimburse administrative medical examinations and reports at an IHCP’s IHS encounter rate. Administrative medical examinations and reports are not eligible under the Memorandum of Agreement (MOA). The Division shall reimburse providers for Administrative Examinations and Reports on a fee-for-service basis outside the IHS or cost-based encounter rate.

(2) AI/AN Health Care Facilities may be reimbursed for administrative medical examinations and reports when requested by a Department of Human Services branch office or approved by the Division. The branch office may request an Administrative Medical Examination/Report Authorization (OHP 729) to establish client eligibility for an assistance program or casework planning.

(3) Refer to OAR 410 division 150, Administrative Examination and Report Billing Services, for specific requirements. See Administrative Exams Supplemental Information guide for more detailed information on procedure codes and descriptions.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0200 Pharmacy

(1) A valid encounter excludes pharmaceutical or biologicals not generally provided during a clinic visit:

(a) An IHS or Tribal 638 Pharmacy may select whether to be reimbursed by the Division for prescriptions, including dispensing services, at the appropriate 340(B) or Federal Supply Schedule Acquisition Rate (refer to OAR 410-121-0160) plus the dispensing fee as determined by the state, or at the All-Inclusive Rate (AIR) published annually by the IHS, inclusive of dispensing fees;

(b) An IHS or Tribal 638 Pharmacy may request to change from the appropriate 340(B) or Federal Supply Schedule Acquisition Rate plus a dispensing fee methodology, to the IHS All-Inclusive Rate (AIR) methodology, or from the IHS AIR methodology to the appropriate 340(B) or Federal Supply Schedule Acquisition Rate (AAC) plus dispensing fee methodology, but no more frequently than four times in a calendar year. Requests must be submitted at least 30 days in advance and shall be effective at the start of the following quarter. If an IHS or Tribal 638 Pharmacy experiences circumstances requiring a methodology change, the 30 day advance notice may be waived and the process.

(2) IHCPs may bill directly the Division only for contraceptive supplies and contraceptive medications outside of the pharmacy program:

(a) For clients enrolled with a PHP, IHCPs must bill the PHP first. If the PHP will not reimburse for the contraceptive supply or contraceptive medication, then the clinic may bill the Division fee-for-service at the clinic’s acquisition cost. See also OAR 410-130-0585, Family Planning Services;

(b) For clients not enrolled with a PHP, IHCPs may bill directly the Division fee-for-service at the clinic’s acquisition cost for contraceptive supplies and contraceptive medications. See also OAR 410-130-0585, Family Planning Services.

(3) Refer to OAR 410 division 121, Pharmaceutical Services program for specific information.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 24-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 39-2002, f. 9-13-02, cert. ef. 9-15-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0220 Death With Dignity

(1) Death with Dignity is a covered service, except for those facilities limited by the Assisted Suicide Funding Restriction Act of 1997 (ASFRA), and is incorporated in the "comfort care" condition/treatment line on the HERC’s Prioritized List of Health Services.

(2) All Death with Dignity services must be billed directly to the Division, even if the client is in a prepaid health plan. Death with Dignity services are not part of the AI/AN encounter rate.

(3) Follow criteria outlined in OAR 410-130-0670.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 28-1999, f. & cert. ef. 6-4-99
OMAP 22-1999(Temp), f. & cert. ef. 4-1-99 thru 9-1-99
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0240 Transportation

(1) The Division may reimburse IHCP for medically appropriate sedan car or wheelchair van transportation services provided to OHP AI/AN clients who receive medical services through an IHCP. (Refer to OAR 410 Division 136, Medical Transportation.)

(2) Federal regulations in 42 CFR 431.53 require the state to ensure necessary transportation for Medicaid recipients to and from providers. The IHCP must ensure that:

(a) The service to be provided is the most cost-effective method that meets the medical needs of the client; and

(b) The service to be provided at the point of origin and destination is a Division Medicaid-covered service according to a client’s OHP benefit package;

(c) In addition, AI/AN OHP clients may be transported to the nearest Tribal Health facility and are not restricted to the nearest (non-tribal) facility able to meet the client’s medical needs.

(3) For the purpose of this rule, the most “cost effective” method is a transportation service that cannot, in the judgment of the Division, be provided through a less expensive alternative while meeting the medical needs of the client. Reimbursement by the Division to an IHCP may not exceed the most cost-effective method and is the lesser of:

(a) The providers costs for furnishing transportation services; or

(b) The amount reimbursed by the Division to non-emergency transportation providers under OAR 410 Division 136 Medical Transportation Program.

(4) The Division shall reimburse transportation services fee-for-service, and outside of the IHS encounter rate, when the IHCP meets the following conditions:

(a) The IHCP owns or leases the sedan car or wheelchair van; and

(b) The individual providing the service is an employee of the IHCP.

(5) IHCPs do not need to enroll separately as a transportation provider if they furnish either sedan car or wheelchair van transportation. As used in this rule, transportation services by IHCPs are defined as follows:

(a) Transportation provided by a 4-door sedan or mini-van motor vehicle having a seating capacity of not less than four and not more than seven passengers;

(b) Transportation provided by a wheelchair lift equipped vehicle for a client who uses a wheelchair. Transportation is generally a "door to door" service. At times, an individual being transported must be picked up inside their residence and taken inside their destination (escort by the driver).

(6) Under the following conditions, an IHCP is required to separately enroll with the Division as a provider of medical transportation services:

(a) The IHCP serves all clients as a whole and does not limit services to the AI/AN community (e.g., Native American clients);

(b) The IHCP owns and operates a taxi service; or

(7) Non-emergency ambulance, air ambulance, commercial air, bus, or train are not reimbursed under this rule to IHCPs and requires advance arrangement and prior authorization (PA) through the local Aging and People with Disabilities Division (APD) or Self Sufficiency Programs branch office.

(8) For all claims submitted to the Division, the provider records must contain completed documentation (pertinent to the service provided) that includes but is not limited to:

(a) Trip information including:

(A) Date of service;

(B) If one way, round trip, or three-way and if transportation needs are ongoing;

(D) Number of actual patient miles traveled; and

(E) Physical address and name of the destination point, e.g., hospital name, doctor name, address, etc.

(b) Client information including:

(A) Client name;

(B) ID number; and

(C) Medical assistance needs (e.g., requires wheelchair, walker, cane, needs assistance, requires portable oxygen, etc.); and

(9) All required documentation must be retained in the provider files for the period of time specified in the General Rules (OAR 410 Division 120).

(10) Medical transportation services must be billed in the professional claim format using the billing instructions and procedure codes in this rule and in conjunction with OAR 410 division 136 Medical Transportation Program.

(11) If two or more Medicaid clients are transported by the same mode (e.g., wheelchair van) at the same time, the Division shall reimburse at the full base rate for the first client and one-half the appropriate base rate for each additional client. If two or more Division clients are transported by mixed mode (e.g., wheelchair van and ambulatory) at the same time, the Division shall reimburse at the full base rate for the highest mode for the first client and one-half the base rate of the appropriate mode for each additional client. Reimbursement may not be made for duplicated miles traveled. If more than one client is transported from a single pickup point to different destinations or from different pickup points to the final destination, the total mileage may be billed. The first ten miles is included in the base rate and should be included in the total number of miles on the CMS-1500 (OAR 410-136-0080, Additional Client Transport).

(12) Tribal facility owned/leased sedan car:

(a) S0215 -- Non-emergency transportation; mileage, per mile;

(b) Not eligible for base rate or extra attendant reimbursement.

(13) Tribal facility owned/leased wheelchair car/van. The Division's reimbursement of the first ten miles of a transport is included in the payment for the base rate. A service from point of origin to point of destination (one-way) is considered a "transport."

(14) Tribal facility owned/leased wheelchair van:

(a) If a client is able to transfer from wheelchair to car/van, the Division may not make payment for wheelchair services for transportation of ambulatory (capable of walking) clients (e.g., base rate, extra attendant);

(b) Wheelchair van -- Bill using the following procedure codes:

(A) A0130 -- Non-emergency transportation, wheelchair car/van base rate;

(B) S0209 -- Wheelchair van, ground mileage, per statute mile;

(15) When billing transportation services, use the appropriate place of service (POS) codes and modifiers as listed in the Medical Transportation Services Supplemental Information guidebook to indicate the type of transportation service and point of origin and destination.

(16) The Division may recoup such payments if, on subsequent review, it is found that the provider did not comply with the Division’s administrative rules. Non-compliance includes, but is not limited to, failure to adequately document the service and the need for the service.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 46-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 59-2002, f. & cert. ef. 10-1-02
OMAP 14-2002, f. & cert. ef. 4-1-02
OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 2-1999, f. & cert. ef. 2-1-99

Or. Admin. R. 410-146-0440 Prepaid Health Plan Supplemental Payments

(1) Effective January 1, 2001, the Division is required by 42 USC 1396a(bb) to make supplemental payments to eligible Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) that contract with Prepaid Health Plans (PHP). American Indian/Alaska Native (AI/AN) program providers that are not FQHCs and that elect to receive payment under Title XIX and XXI according to the Indian Health Services (IHS) rate under the Memorandum of Agreement (MOA) effective July 11, 1996 will also be eligible to receive supplemental payments in the same manner as an FQHC under 1902(bb)(5).

(2) IHCPs reimbursed according to a cost-based rate under the Prospective Payment System (PPS) are directed to Oregon administrative rule (OAR) 410-147-0460, Prepaid Health Plan Supplemental Payments.

(3) The PHP supplemental payment represents the difference, if any, between the payment received by the IHCP from the PHP for treating the PHP enrollee and the payment to which the IHCP would be entitled if they had billed the Division directly for these encounters according to the clinic’s IHS rate.

(4) In accordance with federal regulations, the provider must take all reasonable measures to ensure that in most instances, with the exception of IHS or designated Tribal funds, Medicaid shall be the payer of last resort. Providers must make reasonable efforts to obtain payment first from other resources before submitting claims to the PHP (refer to OAR 410-120-1140, Verification of Eligibility).

(5) When any other coverage is known to the provider, the provider must bill the other resource prior to billing the PHP. When a provider receives a payment from any source prior to the submission of a claim to the PHP, the amount of the payment must be shown as a credit on the claim in the appropriate field (see OAR 410-120-1280, Billing and 410-120-1340, Payment).

(6) Supplemental payment by the Division for encounters submitted by IIHCPs for purposes of this rule is reduced by any and all payments received by the IHCP from outside resources, including Medicare, private insurance, or any other coverage. IHCPs are required to report all payments received on the Managed Care Data Submission Worksheet, including:

(a) Medicaid PHPs;

(b) Medicare Advantage Managed Care Organizations (MCO);

(d) Any third party resources (TPR).

(7) The Division shall calculate the PHP supplemental payment in the aggregate of the difference between total payments received by the IHCP to include payments as listed in section (6) of this rule and the payment to which the IHCP would have been eligible to claim as an encounter if they had billed the Division directly according to the IHS encounter rate.

(8) IHCPs must submit their clinic’s data using the Managed Care Data Submission Template developed by the Division to report all PHP encounter and payment activity.

(9) To facilitate the Division processing PHP supplemental payments, the IHCP must submit the following:

(a) To PHPs:

(A) Claims within the required timelines outlined in the contract with the PHP and in OAR 410-141-0420, Oregon Health Plan Prepaid Health Plan Billing Payment under the OHP;

(B) The AI/AN National Provider Identifier (NPI) number and applicable associated taxonomy code registered with the Division for the health center must be used when submitting all claims to the PHPs.

(b) To the Division:

(A) Report total payments for all services submitted to the PHP:

(i) Including laboratory, radiology, nuclear medicine, and diagnostic ultrasound; and

(ii) Excluding any bonus or incentive payments.

(B) Report total payments for each category listed in the “Amounts Received during the Settlement Period” section of the Managed Care Data Submission Template coversheet;

(C) Payments must be reported at the detail line level on the Managed Care Data Submission Template worksheet, except for capitated payments, or per member per month and risk pool payments received from the PHP;

(D) The total number of actual encounters. An encounter represents all services for a like service element (medical, dental, mental health, or alcohol and chemical dependency) provided to an individual client on a single date of service. The total number of encounters is not the total number of clients assigned to the IHS or Tribal 638 facility or the total detail lines submitted on the Managed Care Data Submission Template worksheet;

(E) A list of individual practitioners with active Division enrollment including names, legacy Division provider number, and NPI number assigned to practitioners associated with the IHS or Tribal 638 facility. “Associated” refers to a practitioner who is either subcontracted or employed by the IHCP;

(F) A current list of all PHP contracts. An updated list of all PHP contracts must be submitted annually to the Division no later than October 31 of each year.

(10) PHP supplemental payment process:

(a) The Division processes PHP supplemental payments on a quarterly basis. The quarterly settlement includes a final reconciliation for the reported time period;

(b) Upon processing a clinic’s data and the PHP supplemental payment, the Division shall:

(A) Send a check to the IHCP for PHP supplemental payment calculated from clinic data the Division was able to process;

(B) Provide a cover letter and summary of the payment calculation; and

(c) The IHCP is responsible for reviewing the data the Division was unable to process for accuracy and completeness. The clinic has 30 days from the date of the Division’s cover letter under section (9) of this rule to make any corrections to the data and resubmit to the Division for processing. Documentation supporting any and all changes must accompany the resubmitted data. A request for extension must be received by the Division prior to expiration of the 30 days and must:

(A) Be in writing;

(B) Be accompanied by a cover letter fully explaining the reason for the late submission; and

(d) Within 30 days of the Division’s receipt of the re-submitted data, the Division shall:

(A) Review the data and issue a check for all encounters the Division verifies to be valid; and

(B) For quarterly data submissions, send a letter outlining the final quarterly settlement including any other pertinent information to accompany the check.

(e) The IHCP must submit data to the Division within the timelines provided by the Division.

(11) Clinics must carefully review in a timely fashion the data that the Division was unable to process and returns to the IHCP. If clinics do not bring any incomplete, inaccurate, or missing data to the Division’s attention within the time frames outlined, Division may not process an adjustment.

(12) The Division encourages IHCPs to request PHP supplemental payment in a timely manner.

(13) Clinics must exclude from a clinic’s data submission for PHP supplemental payment services provided to a PHP-enrolled non-AI/AN client denied by the PHP because the clinic does not have a contract or agreement with the PHP. This may not apply to family planning services or HIV/ AIDS prevention services. Family planning and HIV/AIDS prevention services provided to a PHP-enrolled client when a clinic does not have a contract or agreement with the PHP:

(a) Must be reported in the clinic’s data submission for PHP supplemental payment if the clinic receives payment from the PHP;

(b) May not be reported in the clinic’s data submission for PHP supplemental payment if the clinic is denied payment by the PHP. If the PHP denies payment to the clinic, the clinic may bill these services directly to the Division.

(14) If a PHP denies payment to a contracted IHCP for all services, items, and supplies provided to a client on a single date of service and meeting the definition of an “encounter” as defined in OAR 410-146-0085 for the reason that all services, items, and supplies are non-covered by the plan, the Division may or may not make a supplemental payment to the clinic. The following examples are excluded from the provision of this rule:

(a) Encounters that will later be billed to the PHP as a covered global procedure (e.g., Obstetrics Global Encounter);

(b) If payment received by Medicare and any other third party resource does not exceed the payment the PHP would have made, the PHP would make payment;

(c) At least one of the detail lines reported for all services, items and supplies provided to a client on a single date of service and represents an “encounter,” has a reported payment amount by the PHP.

(15) The Division may not reimburse some Medicaid-covered services that are only reimbursed by PHPs and are not reimbursed by the Division. The Division may not make PHP supplemental payment for these services, as the Division does not reimburse these services when billed directly to the Division.

(16) It is the responsibility of the IHCP to refer PHP-enrolled non-AI/AN clients back to their PHP if the IHCP does not have a contract with the PHP, and the service to be provided is not family planning or HIV/AIDS prevention. The provider assumes full financial risk in serving a person not confirmed by the Division as eligible on the date of service. See OAR 410-120-1140, Verification of Eligibility. The provider must verify:

(a) That the individual receiving medical services is eligible on the date of service for the service provided; and

(b) Whether a client is enrolled with a PHP or receives services on an “open card” or fee-for-service basis.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 7-2011, f. 6-6-11, cert. ef. 7-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 24-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04

Or. Admin. R. 410-146-0460 Compensation for Outstationed Eligibility Workers

(1) The Division may provide reasonable compensation for activities directly related to the receipt and initial processing of applications for individuals to apply for Medicaid at outstationed locations other than state offices.

(2) The Division may provide reasonable compensation to eligible IHCPs for outreach activities performed by Outstationed Outreach Workers (OSOW) equal to 100 percent of direct costs.

(3) IHCPs must submit a budget each December 1 to the Division for review of the clinic OSOW costs for approval before any OSOW compensation is made each January 1.

(4) IHCPs must be compliant with OAR 410-120-0045 Applications for Medical Assistance at provider locations to be eligible for compensation under this rule.

(5) For staff employed by a clinic and performing outreach activities at less than full time, the clinic must calculate the percent of time spent performing OSOW services and maintain adequate documentation to support the percentage of time claimed. The percent must be used to calculate personnel expenses incurred by an IHCP as outlined in section (7) of this rule and that are directly attributed to outreach activities performed by the employee.

(6) Case management is excluded from OSOW reimbursement. If an OSOW also does case management, calculate the OSOW expense as outlined in section (5) above.

(7) Direct cost expenses allowed for OSOW reimbursement:

(a) Personnel costs for OSOWs:

(A) Salary/wages;

(B) Taxes;

(D) Premiums paid by the IHCP for private health insurance.

(b) Travel expenses incurred by the IHCP for the Division training on OSOW activities;

(d) Reasonable equipment necessary to perform outreach activities. A Tribal 638 provider reimbursed according to a cost-based rate may not include expenses for replacing equipment if the original cost of the equipment was reported on the cost statement when the clinic's initial cost-based encounter rate was calculated;

(e) Rent or space costs. A Tribal 638 provider reimbursed according to a cost-based rate may not include rent or space costs if 100 percent of facility costs were reported on the cost statement when the clinic's initial cost-based encounter rate was calculated;

(f) Reasonable office supplies necessary to perform outreach activities; and

(g) Postage.

(8) The Division excludes indirect costs relating to OSOW activities to Tribal 638 providers reimbursed according to a cost-based rate. Excluded indirect costs include and are not limited to the following:

(a) Any costs included in the initial calculation of a Tribal 638 clinic's cost-based encounter rate;

(b) Contracted interpretation services;

(d) Operating expenses including utilities, building maintenance and repair, and janitorial services.

(9) IHS and Tribal 638 facilities that have a Medicaid Administrative Match contract that includes outreach costs are not eligible for separate outreach payments. IHS and Tribal 638 facilities may not participate in the Medicaid Administrative Claiming (MAC) program if they are receiving OSOW compensation according to this rule.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017
DMAP 7-2011, f. 6-6-11, cert. ef. 7-1-11
DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04

Or. Admin. R. 410-146-0470 Traditional Health Care Practices

(1) Definitions:

(a) Indian Health Care Provider (IHCP) means a health care program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise known as an I/T/U) as those terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. § 1603).

(b) Medicaid Management Information System (MMIS) means the automated claims processing and information retrieval system for handling all Medicaid transactions. The objectives of the system include verifying provider enrollment and client eligibility, managing health care provider claims and benefit package maintenance, and addressing a variety of Medicaid business needs

(c) National Provider Identifier means a unique 10-digit number that is issued by the Centers for Medicare and Medicaid and is used to identify health care providers throughout the health care industry.

(d) Prospective Payment System means the method of reimbursement in which payment is made based on a pre-determined, fixed amount.

(e) IHCP Prospective Payment Rates (PPS) means payments made to an IHCP that is based on a clinic-specific, cost-based rate, calculated according to each IHCP’s reported costs and volume of patient encounters.

(f) Tribal-Based Practices means those practices that are based on cultural principles that have been traditionally used in tribal communities since time immemorial. Tribal-Based Practices are culturally validated utilizing the process that has been established and been approved by the review panel of tribal representatives. Not all Tribal-based practices are eligible for Medicaid reimbursement.

(g) Traditional Health Care Practices means those Tribal-based practices that have been determined to be eligible for Medicaid reimbursement.

(h) Tribal Based Practices Review Panel means the panel comprised of tribal representatives who have been elected by representatives from the Nine Federally Recognized Tribes of Oregon. The Tribal Based Practices Review Panel is responsible for accepting, reviewing, and approving Tribal based practices that have been proposed and submitted to the Tribal Based Practices Review Panel for review and approval when evidence, based on research, practice, and culture-based knowledge, shows the Tribal-based practice to be effective. The Tribal Based Practices Review Panel may also provide technical assistance on an ongoing basis to the Tribes and Tribal Organizations regarding Tribal Based Practices. The panel meets on an as-needed basis. Review panel membership is determined by tribal representatives from the Nine Federally Recognized Tribes of Oregon.

(i) Traditional Knowledge Keeper(s) means the individual(s) responsible for providing the Tribal Based Practices. Traditional Knowledge Keepers have gained the traditional knowledge according to their Tribal community that is necessary to implement Tribal Based Practices in a meaningful, respectful, and purposeful way. Examples of Traditional Knowledge Keepers may include elders, cultural or spiritual advisors, traditional foods providers, medicines gatherers, sweat lodge leaders, Tribal singers, dancers, artists, and more. These individuals must meet the qualifications in Section (5) of this rule and are authorized to provide Tribal Based Practices as an employee or contractor of an IHCP.

(j) Urban Indian Health Program (UIHP) means an urban Indian organization as defined in section 1603 of Title 25 that has an IHS Title V contract as described in Section 1653 of Title 25.

(2) Eligibility to Receive Tribal-Based Practices: To be eligible to receive one or more Tribal-Based Practice(s), an individual must meet the following criteria:

(a) Is enrolled in Medicaid or CHIP; and,

(b) Is able to receive services delivered by an Indian Health Care Provider (IHCP), as determined by the IHCP.

(3) Delivery of Traditional Health Care Practices to Qualifying Individuals

(a) The IHCP shall provide Traditional Health Care Practices to qualifying Medicaid or CHIP Members through employed or contracted Traditional Knowledge Keepers.

(b) The Tribal Based Practices Review Panel shall review and maintain a list of available Tribal-Based Practices and the scope of each service. This list will identify the Tribal-Based Practices that are also approved as Traditional Health Care Practices and covered by Medicaid.

(c) The IHCP shall determine the list and scope of each Traditional Health Care Practices that will be offered to qualifying Medicaid and CHIP Members at each IHCP.

(d) Traditional Health Care Practices shall not be subject to OHP’s Prioritized List of Services as described in OAR 410-141-3830.

(e) The IHCP shall maintain internal supporting documentation relating to the provision of the service for the OHP enrolled Member in accordance with OAR 410-120-1360.

(4) Reimbursement for the Delivery of Tribal Based Practices

(a) The IHCP shall be permitted to seek Medicaid reimbursement for expenditures on any Traditional Health Care Practice following the requirements outlined in this section.

(b) The IHCP shall ensure that all Medicaid claims, even those claims that are for Traditional Health Care Practices provided to OHP Members enrolled in Coordinated Care Organizations (CCOs), are submitted to the Authority directly with the applicable information that identifies the IHCP as the Billing Provider, and the Traditional Knowledge Keeper identified as the Rendering Provider. The IHCP shall not submit Medicaid claims relating to the provision of Traditional Health Care Practices to CCOs.

(c) The IHCP shall ensure that diagnosis code Z7689 and procedure code H0051 are used for the reimbursement of all Tribal-Based Practices claims.

(d) The Authority shall process all Traditional Health Care Practices claims at the IHCP’s chosen specified encounter rate (Indian Health Service (IHS) or Prospective Payment System Rates (PPS)).

(e) The Authority shall not provide Traditional Health Care Practice reimbursement for the following items or services:

(A) Construction costs (including building modification and building rehabilitation);

(B) Room and board;

(D) Research grants and expenditures not related to monitoring and evaluation.

(f) Payment for permissible claims submitted for the provision of Traditional Health Care Practices shall be contingent on the availability of federal funding.

(5) Provider Qualifications for Traditional Knowledge Keepers

(a) The IHCP shall be responsible for confirming that all contracted and employed Traditional Knowledge Keepers meet the qualifications described in this Section 5.

(b) In order to receive OHP reimbursement for the provision of Traditional Health Care Practices, a Traditional Knowledge Keeper must be, at the time the practice was performed:

(A) Be employed or contracted with an IHCP.

(B) Meet Traditional Knowledge Keeper qualifications, as determined by the IHCP.

(C) Have the necessary experience and appropriate training to serve as a Traditional Knowledge Keeper, as determined by the IHCP.

(A) Establish methods for determining whether its employees or contractors are qualified to serve as Traditional Knowledge Keepers.

(B) Bill the Authority for Traditional Health Care Practices furnished only by Traditional Knowledge Keepers who are qualified to provide them, as determined by the IHCP.

(d) Each IHCP shall send the Authority a list of employed or contracted Traditional Knowledge Keepers, which must be updated as changes occur. Each IHCP must provide the Authority with copies of any updated list as they occur.

(e) Each Traditional Knowledge Keeper on the list described in (5)(d) shall enroll with Oregon Health Plan (OHP) Open Card by submitting the necessary provider forms to OHA.

(A) An IHCP shall not submit any claim for payment for the provision of any Traditional Health Care Practice by a Traditional Knowledge Keeper if such Traditional Knowledge Keeper was not enrolled with the Authority as required under this subsection at the time the practice was performed.

(B) Traditional Knowledge Keepers shall not be required to have a National Provider Identifier (NPI) number.

(f) The Authority shall verify that the Traditional Knowledge Keeper is on the list provided by each IHCP, as described in (5)(d) of this rule

(g) Once verified, the Authority shall enroll the Traditional Knowledge Keeper in Medicaid Management Information System (MMIS).

History

Statutory/Other Authority: 25 U.S.C. § 1603
Statutes/Other Implemented: 25 U.S.C. § 1603
DMAP 78-2025, adopt filed 10/23/2025, effective 10/23/2025
DMAP 43-2025, temporary adopt filed 04/30/2025, effective 05/01/2025 through 10/27/2025

Or. Admin. R. 410-146-5000 Indian Managed Care Entities

(1) Definitions. The definitions in OAR 410-141-3500 apply to this rule unless context dictates otherwise. In addition, for purposes of this rule:

(a) “The Authority” means the Oregon Health Authority;

(b) “Contract” means an agreement between the State of Oregon and an Indian Managed Care Entity to provide Primary Care Case Management services to eligible members;

(c) “Indian Managed Care Entity (IMCE)” means a managed care entity that is controlled by the Indian Health Service, a Tribe, Tribal Organization, or Urban Indian Organization, or a consortium thereof, as described in 42 U.S.C. § 1396u-2(h)(4)(B) and 42 C.F.R. § 438.14(a);

(d) “Client” means an Oregon Health Plan client who is American Indian or Alaska Native (AI/AN) as defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, under 42 CFR 136.12; or as defined under 42 CFR 438.14(a).;

(e) “Member” means a client enrolled with an IMCE;

(f) “Primary Care Case Management (PCCM) Services” means the location, coordination and monitoring of primary health care services for members. PCCM services may include:

(A) The provision of intensive telephonic or face-to-face case management, including operation of a nurse triage advice line;

(B) The development of enrollee care plans;

(C) The execution of contracts with, or oversight responsibilities for, the activities of fee-for-service (FFS) providers in the FFS program;

(D) The provision of payments to FFS providers on behalf of the State;

(E) The provision of enrollee outreach and education activities;

(F) The operation of a customer service call center;

(G) Review of provider claims, utilization, and practice patterns to conduct provider profiling or practice improvement;

(H) Implementation of quality improvement activities, including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers;

(I) Coordination with behavioral health systems/providers; and

(J) Coordination with long-term services and supports systems/providers.

(2) IMCE PCCM Services: General Standard. The Authority will reimburse an IMCE for PCCM services furnished to eligible members in accordance with a duly executed IMCE contract. The Authority shall ensure that:

(a) All necessary federal approvals are obtained in order to ensure the availability of federal financial participation for PCCM services furnished by IMCEs;

(b) IMCE contracts are executed in accordance with, and require IMCEs to comply with:

(A) Applicable federal law, including 42 U.S.C. § 1396u-2(h) and 42 C.F.R. Part 438; and

(B) Applicable state law, including this rule.

(3) Reimbursement. An IMCE will receive a Per Member Per Month payment, calculated by the Authority in accordance with the contract. This payment will be prorated for any member who is enrolled for less than a full month.

(a) IMCE payments will be generated on a monthly basis.

(b) Should the Authority identify an overpayment (due to, for example, member disenrollment or ineligibility), the overpayment will be recouped from subsequent IMCE payments.

(4) Member Attribution: IMCEs Operated by a Tribe or Tribal Organization.

(a) An individual is potentially eligible to enroll in a Tribal IMCE if the individual:

(A) Is an American Indian or Alaska Native, as defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, under 42 CFR 136.12; or as defined under 42 CFR 438.14(a)

(B) May reside within the Tribe’s purchased and referred care service delivery area (PRCDA);

(D) Is not currently enrolled with another IMCE or a Coordinated Care Organization (CCO).

(b) A Tribal IMCE has the discretion to decide which eligible individuals to enroll and how many eligible individuals to enroll, subject to compliance with:

(A) Any applicable contract provisions; and

(B) Applicable state and federal laws that prohibit discrimination based on disability and other protected traits.

(c) The IMCE will, on a monthly basis, submit to the Authority a patient attribution form listing the IMCE’s enrolled members, as specified in the contract. The Authority will confirm the eligibility of all members before processing IMCE payments.

(5) Member Attribution: IMCEs Operated by an Urban Indian Organization.

(a) An individual is potentially eligible to enroll in an Urban Indian IMCE if the individual:

(A) Is an American Indian or Alaska Native, as defined in OAR 410-141-3500;

(B) Resides within the service area designated in the contract;

(D) Is not currently enrolled with another IMCE or a CCO.

(b) In accordance with the contract, the Authority will periodically generate and submit to the Urban Indian IMCE a list of individuals that meet the eligibility criteria under subsection (5)(a).

(c) An Urban Indian IMCE has the discretion to decide which eligible individuals to enroll and how many eligible individuals to enroll, subject to compliance with:

(A) Any applicable contract provisions; and

(B) Applicable state and federal laws that prohibit discrimination based on disability and other protected traits.

(6) Enrollment. IMCEs shall comply with applicable contract provisions regarding member enrollment and communication with new members.

(7) Disenrollment. IMCEs are responsible for processing, and notifying the Authority of, member disenrollments, in accordance with applicable contract provisions.

(a) Disenrollments initiated by members. Members have a right to request disenrollment from an IMCE at any time.

(b) Disenrollments initiated by the IMCE.

(A) An IMCE must disenroll any member who is no longer eligible for IMCE PCCM services.

(B) An IMCE may disenroll any member at any time, subject to compliance with subparagraph (7)(b)(C) and any applicable contract provisions.

(C) An IMCE may not select members for disenrollment based on factors that would violate applicable state and federal laws that prohibit discrimination based on disability and other protected traits. In addition, consistent with 42 C.F.R. § 438.56(b)(2), an IMCE may not disenroll a member solely due to:

(i) An adverse change in the member’s health status;

(ii) The member’s utilization of medical services;

(iii) The member’s diminished mental capacity; or

(iv) The member’s uncooperative or disruptive behavior resulting from special needs (except when the member’s continued enrollment seriously impairs the IMCE’s ability to furnish services to either this particular member or other members).

(8) IMCE Member Rights & Responsibilities. An IMCE shall, in accordance with the contract, develop written policies defining member rights and responsibilities, ensuring that members are aware of those rights and responsibilities, and enabling members to exercise their rights.

(a) At a minimum, members have the right to:

(A) Be treated with dignity and respect;

(B) Have choice of one or more friends, family members, member representatives, and/or advocate present during communications with IMCE staff;

(D) Receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency in language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the individual and, as applicable, the legal representative or authorized representative of the individual;

(E) Have written materials explained in a manner that is understandable to the member and be educated about the PCCM model;

(F) Have a clinical record maintained that documents conditions, services received, and referrals made;

(G) Have access to one's own clinical record, unless restricted by federal regulations or state statute;

(H) Transfer of a copy of the clinical record to another provider; and

(I) Be able to make a complaint (“grievance”) with the IMCE and receive a response.

(b) At a minimum, members have the responsibility to:

(A) Treat the IMCE staff members with respect;

(B) Give accurate information for inclusion in the clinical record;

(C) Help the provider or clinic obtain clinical records from other providers that may include signing an authorization for release of information;

(D) Ask questions about conditions, treatments, and other issues related to care that is not understood;

(E) Help in the creation of a care plan;

(F) Inform the IMCE or the Authority of a change of address or phone number; and

(G) Bring issues or complaints or grievances to the attention of the IMCE.

(9) Grievance System. An IMCE must establish a system for member grievances that complies with OAR 410-141-3875 through 410-141-3880, OAR 410-141-3915, and any applicable contract provisions. (An IMCE that does not make service authorization decisions is not required to establish processes for member appeals or contested case hearings.)

(10) Application of Oregon Health Plan Regulations. Subject to the scope of the IMCE contract and to the definitions in subsection (1) above, the following rules apply to IMCEs as though, in these rules, all instances of the term “MCE” were replaced with “IMCE”:

(a) OAR 410-120-0000 (Acronyms and Definitions);

(b) OAR 410-141-3530 (Definitions);

(c) OAR 410-141-3501 (Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation; Rule Precedence);

(d) OAR 410-141-3505 (Use of Subcontractors);

(e) Sections (9) through (13) of OAR 410-141-3520 (Record Keeping and Use of Health Information Technology);

(f) OAR 410-141-3530 (Sanctions);

(g) OAR 410-141-3550 (Resolving Disputes with OHA);

(h) OAR 410-141-3575 (Member Relations, Marketing);

(i) OAR 410-141-3580 (Potential Member Information);

(j) OAR 410-141-3585 (Member Relations: Education and Information); and

(k) Sections (1) through (10) of OAR 410-141-3710 (Contract Termination and Close-Out Requirements).

History

Statutory/Other Authority: ORS 413.042, 42 U.S. Code § 1396u–2 & 42 CFR § 438.14
Statutes/Other Implemented: ORS 413.042
DMAP 57-2022, adopt filed 06/21/2022, effective 06/22/2022
DMAP 36-2022, temporary adopt filed 02/25/2022, effective 03/01/2022 through 08/27/2022

Division 147 FQHC AND RHC SERVICES

Or. Admin. R. 410-147-0000 Foreword

(1) The Division of Medical Assistance Programs” (Division) Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) rules are designed to assist FQHCs and RHCs to deliver health care services and prepare health claims for clients with Medical Assistance Program coverage.

(2) The FQHC and RHC rules contain important information including general program policy, provider enrollment, and maintenance of financial records, special programs, and billing information.

(3) It is the clinic’s responsibility to understand and follow all Division rules that are in effect on the date services are provided.

(4) Typically rules are modified twice a year, April for technical changes and October for technical and/or program changes. Technical changes refer to operational information. All provider rules can be found on the Division website.

(5) FQHCs and RHCs must use rules contained in the FQHC and RHC rules. Do not use other provider rules unless specifically directed in rules contained in the FQHC and RHC rules. Division General Rules and the Oregon Health Plan (OHP) Administrative Rules are intended to be used in conjunction with all program rules including the FQHC and RHC provider rules.

(6) The Health Services Commission’s Prioritized List of Health Services is found in the OHP Administrative Rules (OAR 410-141-0520) and defines the services covered under Division.

(7) An FQHC is defined as a clinic that is recognized and certified by the Centers for Medicare and Medicaid Services (CMS) as meeting federal requirements as an FQHC.

(8) An RHC is defined as a clinic that is recognized and certified by CMS as meeting federal requirements for payment for RHC services.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
OMAP 47-2005, f. 9-9-05, cert. ef. 10-1-05
OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0000
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0000
OMAP 42-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99
HR 24-1996, f. 11-29-96, cert. ef. 12-1-96
HR 13-1996(Temp), f. & cert. ef. 7-1-96
HR 24-1992, f. & cert. ef. 7-3-92
HR 12-1992, f. & cert. ef. 4-1-92
HR 33-1991, f. & cert. ef. 8-16-91, Renumbered from 461-014-0415
HR 29-1991(Temp), f. & cert. ef. 7-1-91
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91
AFS 47-1989, f. & cert. ef. 8-24-89
AFS 16-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 20-1988, f. 3-8-88, cert. ef. 4-1-88

Or. Admin. R. 410-147-0020 Professional Ambulatory Services

(1) Providers must use the following rules in conjunction with all individual program rules to determine service coverage and limitations for Oregon Health Plan (OHP) clients according to their benefit packages: Medical, EPSDT, Diagnostic, Dental, Vision, Physical Therapy, Occupational Therapy, Podiatry, Mental Health, Alcohol and Chemical Dependency, Maternity Case Management, Speech, Hearing, and Home Health services are governed by the Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) rules (OAR 410 division 147), General Rules (410 division 120), OHP Administrative Rules (410-141-0480, 410-141-0500, and 410-141-0520), and the Health Services Commission's (HSC) Prioritized List of Health Services (List), and the Oregon Health Authority (Authority) rules related to provider enrollment and claiming (943-120-0300 through 0380).

(2) Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are eligible for reimbursement of covered professional services provided within the scope of the clinic and within the individual practitioner’s scope of license or certification. See also OAR 410-147-0120(6). For the purposes of this rule, a clinic's "scope" refers to authorization or certification to provide services if required:

(a) For FQHCs only, services must be provided in accordance with the FQHC’s scope as approved by the Health Resources and Services Administration (HRSA) Notice of Grant Award Authorization; and

(b) Both FQHCs and RHCs must provide services within the scope of the Addictions and Mental Health Division (AMH) certification for the facility, if required. See OAR 410-147-0320(3) and (5).

(3) The date of service determines the appropriate version of the FQHC and RHC rules, General Rules, and HSC Prioritized List to determine coverage.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0140
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0500
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-147-0040 ICD-10-CM Diagnosis and CPT/HCPCs Procedure Codes

(1) The appropriate ICD-10-CM diagnosis code or codes from 001.0 through V99.9 must be used to identify:

(a) Diagnoses;

(b) Symptoms;

(d) Problems;

(e) Complaints; or

(f) Other reasons for the encounter/visit.

(2) The Division of Medical Assistance Program (DMAP) requires diagnosis codes on all claims, including those submitted by independent laboratories and portable radiology, including nuclear medicine and diagnostic ultrasound providers. A clinic must always provide the client's diagnosis to ancillary service providers when prescribing services, equipment, and supplies.

(3) Clinics must list the principal diagnosis in the first position on the claim. Use the principal diagnosis code for the diagnosis, condition, problem, or other reason for an encounter/visit shown in the medical record to be chiefly responsible for the services provided. Clinics may list up to three additional diagnosis codes on the claim for documented conditions that coexist at the time of the encounter/visit and require or affect client care, treatment, or management.

(4) Clinics must list the diagnosis codes using the highest degree of specificity available in the ICD-10-CM. Use a three-digit diagnosis code only if the diagnosis code is not further subdivided. Whenever fourth-digit or fifth-digit subcategories are provided, the provider must report the diagnosis at that specificity. DMAP considers a diagnosis code invalid if it has not been coded to its highest specificity.

(5) DMAP requires providers to use the standardized code sets required by the Health Insurance Portability and Accountability Act (HIPAA) and adopted by the Centers for Medicare and Medicaid Services (CMS). Unless otherwise directed in rule, providers must accurately code claims according to the national standards in effect for the date the service(s) was provided:

(a) For dental services, use codes that are in effect for the date the service(s) was provided that are found in Dental Procedures and Nomenclature as maintained and distributed by the American Dental Association for dental services;

(b) For health care services, use the combination of Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes in effect for the date the service(s) was provided. These services include, but are not limited to, the following:

(A) Physician services;

(B) Physical and occupational therapy services;

(D) Clinical laboratory tests;

(E) Other medical diagnostic procedures;

(F) Hearing and vision services.

(6) DMAP maintains unique coding and claim submission requirements for Administrative Exams and Death with Dignity services. Refer to OAR 410 division 150, Administrative Examination and Billing Services, and 410-130-0670, Death with Dignity Services, for specific requirements.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 42-2008, f. 12-11-08, cert. ef. 1-1-09
DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
DMAP 10-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0060
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0020
OMAP 19-2001, f. 3-30-01, cert, ef. 4-1-01
OMAP 8-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99
HR 7-1995, f. 3-31-95, cert. ef. 4-1-95
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91

Or. Admin. R. 410-147-0060 Prior Authorization

(2) It is the responsibility of the Provider to verify whether a PHP or Division is responsible for reimbursement. Refer to OAR 410-120-1140 Verification of Eligibility.

(3) If a client is enrolled in a PHP there may be Prior Authorization (PA) requirements for some services that are provided through the PHP. It is the Federally Qualified Health Center (FQHC) or Rural Health Clinic(RHC) responsibility to comply with the PHP’s PA requirements or other policies necessary for reimbursement from the PHP before providing services to any OHP client enrolled in a PHP. The FQHC or RHC needs to contact the client’s PHP for specific instructions.

(4) Clients who are enrolled in a PHP can receive family planning services, human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) prevention services (excludes any treatment for HIV or AIDS) through an FQHC or RHC without PA from the PHP as provided under the terms of Oregon’s Section 1115 (CMS) Waiver. If the FQHC or RHC does not have a contract or other arrangements with a PHP, and the PHP denies payment, the Division of Medical Assistance Programs (Division) will reimburse for these services per a clinic’s encounter rate (see OAR 410-147-0120(12)(b)).

(5) If a client receives services on a FFS basis, a PA may be required by Division for certain covered services or items before the service can be provided or before payment will be made. An FQHC or RHC assumes full financial risk in providing services to a FFS client prior to receiving authorization, or in providing services that are not in compliance with OARs. See OAR 410-120-1320 Authorization of Payment and any applicable program rules.

(6) If the service or item is subject to Prior Authorization, the FQHC or RHC must follow and comply with PA requirements in these rules, the General Rules and applicable program rules, including but not limited to:

(b) The services provided are consistent with the information submitted when authorization was requested;

(d) The services are provided within the timeframe specified on the authorization of payment document.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0080
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0640
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-147-0080 Prepaid Health Plans (PHPs)

(1) Most Oregon Health Plan (OHP) clients have prepaid health services, contracted for by the Oregon Health Authority (Authority) through enrollment in a prepaid health plan (PHP). Clinics serving eligible OHP clients who are enrolled in a PHP must secure authorization from the PHP prior to providing PHP-covered services or case management services. Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) must request an authorization or referral from the PHP before providing any services to clients enrolled in a PHP unless the FQHC or RHC have contracted with the PHP to provide PHP-covered services. If an FQHC or RHC has an arrangement or contract with a PHP, the clinic is responsible to follow PHP rules and prior authorization requirements. See OAR 410 division 141 for OHP Program Rules and; 410-147-0060, Prior Authorization.

(2) The Division of Medical Assistance Programs (Division) encourages FQHCs and RHCs to contact each PHP in their local service area for the purpose of requesting inclusion in their panel of providers.

(3) PHPs contracting with FQHCs or RHCs, for the provision of providing services to their members, are required by 42 USC 1396b(m)(2)(A)(ix) to provide payment to the FQHC or RHC that is not less than the level and amount of payment which the PHP would make for services furnished by a non-FQHC/RHC provider.

(4) Payment for services provided to PHP-enrolled clients (PHP members) is a matter between the FQHC or RHC and the PHP authorizing the services except as otherwise provided in OAR 410-141-0410, OHP primary care managers. If a PHP denies payment to an FQHC or RHC because arrangements were not made with the PHP prior to providing the service, Division will not reimburse the FQHC or RHC under the encounter rate, except as outlined in Section (5) of this rule (see OAR 410-141-0120, OHP PHP Provision of Health Care Services).

(5) FQHCs and RHCs can provide family planning services or Human Immunodeficiency Virus and Acquired Immune deficiency Sydrome prevention services to eligible PHP members without authorization or a referral from the PHP. The FQHC and RHC must bill the PHP first. If the PHP will not reimburse for the service, then the clinic may bill Division. Refer to ORS 414.153, Authorization for payment for certain point of contact services.

(6) PHPs will execute agreements with publicly funded providers, unless cause can be demonstrated to Division’s satisfaction why such an agreement is not feasible for authorization of payment for point of contact services in the following categories (refer to ORS 414.153):

(a) Immunizations;

(b) Sexually transmitted diseases; and

(7) PHPs are responsible to ensure the provision of qualified sign language and oral interpreter services for covered medical, mental health or dental care visits, for their enrolled PHP Members with a hearing impairment or who are non-English speaking. Services must be sufficient for the FQHC or RHC provider to be able to understand the PHP Member's complaint; to make a diagnosis; respond to the PHP Member's questions and concerns; and to communicate instructions to the PHP Member. See OAR 410-141-0220(7), Oregon Health Plan prepaid health plan Accessibility.

(8) The provider assumes full financial risk in serving a person not confirmed by Division as eligible on the date(s) of service. It is the responsibility of the provider to verify a client’s eligibility. Refer to OAR 410-120-1140 Verification of Eligibility:

(a) That the individual receiving medical services is eligible on the date of service for the service provided;

(b) Whether an OHP client receives services on a fee-for-service (open card) basis or is enrolled with a PHP; and

(c) Whether the service is covered by a third party resource (TPR), a PHP, or if Division reimburses on a fee-for-service basis.

(9) Division requires the following of a FQHC or RHC under contract with a PHP:

(a) Clinic must maintain reimbursement and documentation records that will permit calculation of supplemental payments according to OAR 410-147-0460. According to OAR 410-141-0180, Oregon Health Plan prepaid health plan Record Keeping, a PHP’s participating providers shall maintain a clinical record keeping system with sufficient detail and clarity to permit internal and external clinical audit to validate encounter submissions and to assure Medically Appropriate services are provided consistent with the documented needs of the PHP Member. See also OAR 410-120-1360, Requirements for Financial, Clinical and Other Records;

(b) Clinics are subject to ongoing performance review by the PHP. According to OAR 410-141-0200, Oregon Health Plan prepaid health plan Quality Improvement (QI) System, PHPs must maintain an effective process for monitoring, evaluating, and improving the access, quality and appropriateness of services provided to Division Members. The QI program must include QI projects that are designed to improve the access, quality and utilization of services;

(c) Clinics are subject to program review by Division, the Department of Human Services’ Audit Unit, and the Department of Justice Medicaid Fraud Unit for the purposes of assuring program integrity and:

(A) Compliance with Oregon Revised Statutes, Oregon Administrative Rules and Federal laws and regulations;

(B) Use of accurate and complete encounter and fee-for-service claims data, and supporting clinical documentation, for calculating PHP supplemental payments and compensation for out-stationed outreach workers;

(C) Adequate records maintenance for cost reimbursed services to thoroughly explain how the amounts reported on the cost statement were determined. The records must be accurate and in sufficient detail to substantiate the data reported.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0100
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0155
OMAP 42-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99
HR 7-1995, f. 3-31-95, cert. ef. 4-1-95
HR 13-1993, f. & cert. ef. 7-1-93

Or. Admin. R. 410-147-0085 Client Copayments

(1) The Division of Medical Assistance Programs (Division) Medical Care Identification will indicate which Oregon Health Plan (OHP) clients are responsible for copayments for services.

(2) Division requires copayments from clients with certain benefit packages. See OAR 410-120-1230, Client Copayment, and Table 120-1230-1 for specific details.

(3) A client may owe more than one copayment during a 24-hour period. Division may require copayments for each medical, dental, mental health or alcohol and chemical dependency encounter on the same date of service. Refer to OAR 410-147-0140, Multiple Encounters.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 90-2002, f. 12-24-02, cert. ef. 1-1-03

Or. Admin. R. 410-147-0120 Division Encounter and Recognized Practitioners

(1) The Division of Medical Assistance Programs (Division) reimburses Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services according to the Prospective Payment System (PPS) as follows:

(a) When the service(s) meet the criteria of a valid encounter as defined in Sections (2) through (4) of this rule;

(b) Reimbursement is limited to the Division’s Medicaid-covered services according to a client’s Oregon Health Plan (OHP) benefit package. These services include ambulatory services included in the State Plan under Title XIX or Title XXI of the Social Security Act. Other services that are not defined in this rule or the State Plan under Title XIX or Title XXI of the Social Security Act are not reimbursed by the Division.

(2) For the provision of services defined in Titles XIX and XXI and provided through an FQHC or RHC, an “encounter” is defined as a face-to-face or telephone contact between a health care professional and an eligible OHP client within a 24-hour period ending at midnight, as documented in the client's medical record. Section (4) of this rule outlines limitations for telephone contacts that qualify as encounters. For purposes of this rule, a face-to-face “encounter” includes services provided via a synchronous two-way audiovisual link between a patient and a provider per OAR 410-130-0610.

(3) An encounter includes all services, items and supplies provided to a client during the course of an office visit (except as excluded in Sections (6) and (12) of this rule) and those services considered “incident-to.” These services are inclusive of the visit with the core provider meeting the criteria a valid encounter and reimbursed at the PPS all-inclusive encounter rate. These services include:

(a) Drugs or medication treatments provided during a clinic visit are inclusive of the encounter, with the exception of contraception supplies and medications as costs for these items are excluded from the PPS encounter rate calculation (see OAR 410-147-0280 Drugs and OAR 410-147-0480 Cost Statement (DMAP 3027) Instructions);

(b) Medical supplies, equipment, or other disposable products (e.g. gauze, band-aids, wrist brace) are inclusive of an office visit;

(d) Venipuncture for lab tests. The Division does not deem a visit for lab test only to be a clinic encounter;

(4) Telephone encounters qualify as a valid encounter for services provided in accordance with OAR 410-130-0595, Maternity Case Management (MCM) and 410-130-0190, Tobacco Cessation (see also OAR 410-120-1200). Except as set forth below, providers may not make telephone contacts at the exclusion of face-to-face visits.

(a) Telephone encounters must include all the same components of the service as if provided face-to-face.

(5) Extended care services furnished under a contract between a county Community Mental Health Program (CMHP) of the FQHC and Addictions and Mental Health Division (AMH) are reimbursed outside of the PPS. Extended care services are those services provided under AMH’s licensure requirements and reimbursed under AMH’s terms and conditions.

(6) Some Division Medicaid-covered services are not reimbursable when furnished according to Oregon Health Plan (OHP) client’s benefit package as a stand alone service. Although costs incurred for furnishing these services are inclusive of the PPS all-inclusive rate calculation, visits where these services were furnished as a stand-alone service were excluded from the denominator for the PPS rate calculation (see OAR 410-147-0480, Cost Statement (DMAP 3027) Instructions). The following services when furnished as a stand-alone service are not reimbursable:

(a) Sign language and oral interpreter services;

(b) Supportive rehabilitation services including, but not limited to, environmental intervention, supported housing and employment, or skills training and activity therapy to promote community integration and job.

(7) FQHCs and RHCs may provide certain services, items and supplies that are prohibited from being billed under the health centers provider enrollment, and requires separate enrollment (see OAR 410-147-0320(1)(b) Federally Qualified Health Center (FQHC)/Rural Health Clinics (RHC) Enrollment). These services include:

(a) Durable medical equipment, prosthetics, orthotics or medical supplies (DMEPOS) (e.g. diabetic supplies) not generally provided during the course of a clinic visit (refer to OAR chapter 410, division 122, DMEPOS);

(b) Prescription pharmaceutical and/or biologicals not generally provided during the clinic visit must be billed to DMAP through the pharmacy program (refer to OAR chapter 410, division 121, Pharmaceutical Services);

(8) Client contact with more than one health professional for the same diagnosis or multiple encounters with the same health professional that take place on the same day and at a single location constitute a single encounter. For exceptions to this rule, see OAR 410-147-0140 for reporting multiple encounters.

(9) Providers are advised to include all services that can appropriately be reported using a procedure code on the claim and bill as instructed in the appropriate Division program rules and must use the appropriate HIPAA procedure code set such as CPT, HCPCS, ICD-10-CM, ADA CDT, NDC, established according to 45 CFR 162.1000 to 162.1011, which best describes the specific service or item provided. For claims that require the listing of a diagnosis or procedure code as a condition of payment, the code listed on the claim form must be the code that most accurately describes the client's condition and the service(s) provided. Providers must use the ICD-10-CM diagnosis coding system when a diagnosis is required unless otherwise specified in the appropriate individual provider rules (refer to OAR 410-120-1280 Billing and see OAR 410-147-0040 ICD-10-CM Diagnosis and CPT/HCPCs Procedure Codes).

(10) FQHC and RHC services that may meet the criteria of a valid encounter are (refer to individual program administrative rules for service limitations.):

(a) Medical (OAR chapter 410, division 130);

(b) Diagnostic: The Division covers reasonable services for diagnosing conditions, including the initial diagnosis of a condition that is below the funding line on the Prioritized List of Health Services. Once a diagnosis is established for a service, treatment or item that falls below the funding line, the Division will not cover any other services related to the diagnosis;

(d) Dental (see to OAR 410-147-0125, and refer to OAR chapter 410, division 123);

(e) Vision (OAR chapter 410, division 140);

(f) Physical Therapy (OAR chapter 410, division 131);

(g) Occupational Therapy (OAR chapter 410, division 131);

(h) Podiatry (OAR chapter 410, division 130);

(i) Mental Health (Refer to the Division of Addiction and Mental Health (AMH) for appropriate OARs);

(j) Alcohol, Chemical Dependency, and Addiction services (see also OAR 410-147-0320). Requires a letter or licensure of approval by AMH (refer to AMH for appropriate OARs);

(k) Maternity Case Management (MCM) (OAR 410-147-0200);

(L) Speech (OAR chapter 410, division 129);

(m) Hearing (OAR chapter 410, division 129);

(n) The Division considers a home visit for assessment, diagnosis, treatment or MCM as an encounter. The Division does not consider home visits for MCM as home health services;

(o) Professional services provided in a hospital setting; and

p) Other Title XIX or XXI services as allowed under Oregon's Medicaid and CHIP State Plan Amendments and the Division’s administrative rules.

(11) The following practitioners are recognized by the Division:

(a) Doctors of medicine, osteopathy and naturopathy;

(b) Licensed Physician Associates;

(d) Dental Hygienists who hold a Limited Access Permit (LAP) — may provide dental hygiene services without the supervision of a dentist in certain settings. For more information, refer to the section on Limited Access Permits, ORS 680.200 and the appropriate Oregon Board of Dentistry OARs;

(e) Pharmacists;

(f) Nurse Practitioners;

(g) Nurse Midwives;

(h) Other specialized nurse practitioners;

(i) Registered nurses — may accept and implement orders within the scope of their license for client care and treatment under the supervision of a licensed health care professional recognized by the Division in this section and who is authorized to independently diagnose and treat according to appropriate State of Oregon’s Board of Nursing OARs;

(j) Psychiatrists;

(k) Licensed Clinical Social Workers;

(L) Clinical psychologists;

(m) Acupuncturists — Refer to OAR chapter 410, division 130 for service coverage and limitations;

(n) Licensed professional counselor;

(o) Licensed marriage and family therapist; or

(p) Other health care professionals providing services within their scope of practice and working under the supervision requirements of:

(A) Their individual provider’s certification or license; or

(B) A clinic’s mental health certification or alcohol and other drug program approval or licensure by the Addictions and Mental Health Division (AMH) (see OAR 410-147-0320).

(12) Encounters with a registered professional nurse or a licensed practical nurse and related medical supplies (other than drugs and biologicals) furnished on a part-time or intermittent basis to home-bound clients (limited to areas in which the Secretary has determined that there is a shortage of home health agencies — Code of Federal Regulations 42 ¦ 405.2417), and any other ambulatory services covered by the Division are also reimbursable as permitted within the clinic's scope of services (see OAR 410-147-0020).

(13) FQHCs and RHCs may furnish services that are reimbursed outside of the PPS all-inclusive encounter rate and according to the physician fee schedule. These services include:

(a) Administrative medical examinations and report services (refer to OAR chapter 410, division 150);

(b) Death with Dignity services (refer to OAR 410-130-0670);

(c) Services provided to Citizenship Waived Medical (CWM) clients (refer to OARs 410-120-1210, 461-135-1070 and 410-130-0240);

(d) Services provided to Qualified Medicare Beneficiary (QMB) only clients (refer to OAR 410-120-1210, Medical Assistance Benefit Packages and Delivery System). Specific billing information is located in the FQHC and RHC Supplemental Information billing guide; and

(e) Comprehensive environmental lead investigation (refer to OAR 410-130-0245, Early and Periodic Screening, Diagnostic and Treatment Program).

(14) OHP benefit packages and delivery system are described in OAR 410-120-1210. Most OHP clients have prepaid health services, contracted for by the Authority through enrollment in a Prepaid Health Plan (PHP). Non-PHP-enrolled clients, receive services on an "open card" or "fee-for-service” (FFS) basis.

(a) The Division is responsible for making payment for services provided to open card clients. The provider will bill the Division the clinic’s encounter rate for Medicaid-covered services provided to these clients according to their OHP benefit package (see OAR 410-147-0360, Encounter Rate Determination).

(b) A PHP is responsible to provide, arrange and make reimbursement arrangements for covered services for their Division members (refer to OAR 410-120-0250, and OAR chapter 410, division 141, OHP administrative rules governing PHPs). The provider must bill the PHP directly for services provided to an enrolled client (See also OARs 410-147-0080, Prepaid Health Plans, and 410-147-0460, PHP Supplemental Payment). Clinics must not bill the Division for PHP-covered services provided to eligible OHP clients enrolled in PHPs. Exceptions include:

(A) Family planning services provided to a PHP-enrolled client when the clinic does not have a contract with the PHP, and if the PHP denies payment (see OAR 410-147-0060); and

(B) HIV/AIDS prevention provided to a PHP-enrolled client when the clinic does not have a contract with the PHP, and if the PHP denies payment (see OAR 410-147-0060).

(15) Federal law requires that state Medicaid agencies take all reasonable measures to ensure that in most instances the Division will be the payer of last resort. Providers must make reasonable efforts to obtain payment first from other resources before billing the Division (refer to OAR 410-120-1140 Verification of Eligibility).

(16) When a provider receives a payment from any source prior to the submission of a claim to the Division, the amount of the payment must be shown as a credit on the claim in the appropriate field (refer to OARs 410-120-1280 Billing and 410-120-1340 Payment).

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 20-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 17-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 46-2020, amend filed 09/11/2020, effective 09/15/2020
DMAP 11-2020, temporary amend filed 03/20/2020, effective 03/20/2020 through 09/15/2020
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 38-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 47-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 22-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 44-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 49-2004, f. 7-28-04, cert. ef. 8-1-04
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0150
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0390
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 21-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99
HR 7-1995, f. 3-31-95, cert. ef. 4-1-95
HR 13-1993, f. & cert. ef. 71-1-93

Or. Admin. R. 410-147-0140 Multiple Encounters

(1) An encounter is defined in OAR 410-147-0120.

(2) The following services may be considered as multiple encounters when two or more service encounters are provided on the same date of service with distinctly different diagnoses (see OAR 410-147-0120 and individual program rules listed below for specific service requirements and limitations):

(a) Medical section (3) of this rule and OAR chapter 410, division 130);

(b) Dental (OAR 410-147-0125, and OAR chapter 410, division 123);

(c) Mental Health — If a client is also seen for a medical office visit and receives a mental health diagnosis, then the client contacts are a single encounter (Refer to the Division of Addictions and Mental Health (AMH) for the appropriate OARs);

(d) Addiction and Alcohol and Chemical Dependency — If a client is also seen for a medical office visit and receives an addiction diagnosis, then the client contacts area single encounter (Refer to AMH’s OARs);

(e) Ophthalmologic services — fitting and dispensing of eyeglasses are included in the encounter when the practitioner performs a vision examination. (OAR chapter 410, division 140);

(f) Maternity Case Management MCM (OAR 410-147-0200);

(g) Physical or occupational therapy (PT/OT) — If this service is also performed on the same date of service as the medical encounter that determined the need for PT/OT (initial referral), then it is considered a single encounter (OAR chapter 410, division 131);

(h) Immunizations — if no other medical office visit occurs on the same date of service; and

(i) Tobacco cessation — if no other medical, dental, mental health or addiction service encounter occurs on the same date of service (refer to OAR 410-130-0190).

(b) The patient has two or more encounters as described in section (2) of this rule.

(4) A mental health encounter and an addiction and alcohol and chemical dependency encounter provided to the same client on the same date of service will only count as multiple encounters when provided by two separate health professionals and each encounter has a distinctly different diagnosis.

(5) Similar services, even when provided by two different health care practitioners, are not considered multiple encounters. Situations that would not be considered multiple encounters provided on the same date of service include, but are not limited to:

(a) A well child check and an immunization;

(b) A well child check and fluoride varnish application in a medical setting;

(d) A prenatal visit and a delivery procedure;

(e) A cesarean delivery and surgical assist;

(f) Any time a client receives only a partial service with one provider and partial service from another provider, this would be considered a single encounter.

(6) A clinic may not develop clinic procedures that routinely involve multiple encounters for a single date of service. A recipient may obtain medical, dental or other health services from any provider approved by the Division, and/or contracts with the recipient’s PHP, if the Federally Qualified Health Center or Rural Health Clinic (FQHC/RHC) is not the recipient’s primary care manager.

(7) Clinics may not “unbundle” services that are normally rendered during a single visit for the purpose of generating multiple encounters:

(a) Clinics are prohibited from asking the patient to make repeated or multiple visits to complete what is considered a reasonable and typical office visit, unless it is medically necessary to do so;

(b) Medical necessity must be clearly documented in the patient’s record.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 38-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 22-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0155
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0520
OMAP 42-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 19-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 8-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-147-0160 Modifiers

(1) The Division of Medical Assistance Programs (Division) uses HIPAA compliant modifiers for many services.

(2) The following conditions require the use of a modifier for all codes:

(a) Family Planning Service — FP, Refer to OAR 410-130-0585 Family Planning Services

(b) Vaccine for Children — SL or 26, Refer to OAR 410-130-0255(4)

(3) When billing for services that are reimbursed outside a clinic’s encounter rate, a clinic must use the required modifier(s) listed in the individual program Administrative Rules.

(a) Enhanced Care Services (including extended care) — HK, Refer to OAR 410-147-0120;

(b) Assist surgeon for cesarean deliveries for Citizenship Waived Medical (CWM) clients — 80, 81, 82 or AS.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 16-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-147-0180 Vaccines for Children (VFC) Program

(1) The Division of Medical Assistance Programs (Division) will reimburse Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) for the administration of vaccines to eligible clients.

(2) The VFC program supplies federally purchased free vaccines for immunizing eligible client’s ages 0 through 18 at no cost to participating health care providers. For more information on how to enroll in the VFC program, contact the Oregon Health Authority (Authority) Immunization Program. Refer to the FQHC and RHC Supplemental Information for instructions.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0160
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0540
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-147-0200 Maternity Case Management Services

(1) The Division of Medical Assistance Programs (Division) will reimburse federally qualified health centers (FQHCs) and rural health clinics (RHCs) for maternity case management (MCM) services.

(2) MCM service is optional coverage for Prepaid Health Plans (PHPs). Before providing MCM services to a client enrolled in a PHP, determine if the PHP covers MCM services:

(a) If the PHP does not cover MCM services, the provider can bill the Division directly per the clinic’s Prospective Payment System (PPS) encounter rate. Prior authorization is not required if the PHP does not provide coverage for MCM services;

(b) If the PHP does cover MCM services, the provider needs to request the necessary authorizations from the PHP.

(3) Clients’ records must clearly document all MCM services provided including all mandatory topics. Refer to OAR 410-130-0595, Maternity Case Management for specific requirements.

(4) The primary purpose of the MCM program is to optimize pregnancy outcomes, including the reduction of low birth weight babies. MCM services are intended to target pregnant women early during the prenatal period and can only be initiated when the client is pregnant.

(a) MCM services cannot be initiated the day of delivery, during postpartum or for newborn evaluation;

(b) Clients are not eligible for MCM services if the provider has not completed the MCM initial evaluation the day before delivery;

(5) Multiple MCM contacts in a single day do not qualify as multiple encounters.

(6) A medical/prenatal visit encounter and an MCM encounter can qualify as two separate encounters when furnished on the same day only when the MCM service is:

(a) The initial evaluation to receive MCM service; or

(b) A nutritional counseling MCM service provided after the initial evaluation visit. See Section (7) of this rule for limitations.

(7) MCM services limitations:

(a) The Division reimburses the initial evaluation one time per pregnancy per provider;

(b) The Division reimburses nutritional counseling one time per pregnancy if a client meets the criteria in OAR 410-130-0595(14); and

(c) The Division will reimburse a maximum of ten MCM services/visits in addition to (a) and (b) above, providing visits/services are furnished in compliance with OAR 410-130-0595.

(8) Case management services must not duplicate services for case management activities or direct services provided under the State Plan or the Oregon Health Plan (OHP), through fee for service, managed care, or other contractual arrangement, that meet the same need for the same client at the same point in time. This includes Maternity Case Management, and any Targeted Case Management (TCM) Programs outlined in OAR chapter 410, division 138.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 38-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0180
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0560
OMAP 42-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-147-0240 Administrative Medical Examinations and Reports

(1) The Division of Medical Assistance Programs (Division) does not reimburse Administrative Medical Examinations and Reports at a clinic’s encounter rate. Division reimburses providers for Administrative Examinations and Reports on a fee-for-service basis.

(2) Refer to OAR 410 division 150, Administrative Examination and Billing Services, for specific requirements. See Administrative Exams Supplemental Information for more detailed information on procedure codes and descriptions.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0220
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0620
OMAP 21-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-147-0260 Death With Dignity

(1) Death With Dignity is a covered service, except for those facilities limited by the Assisted Suicide Funding Restriction Act of 1997 (ASFRA), and is incorporated in the “comfort care” condition/treatment line on the Health Services Commission’s Prioritized List of Health Services.

(2) All claims for Death With Dignity services must be billed directly to the Division of Medical Assistance Programs (Division), even if the client is in a managed care plan. Death With Dignity services are not part of the Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) encounter rate.

(3) Follow criteria outlined in OAR 410-130-0670.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0260
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0035
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 27-1999, f. & cert. ef. 6-4-99
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 19-1999, f. & cert. ef. 4-1-99
OMAP 16-1999(Temp), f. & cert. ef. 4-1-99 thru 9-1-99

Or. Admin. R. 410-147-0280 Drugs

(1) As defined by the Division of Medical Assistance Programs (Division), a valid Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) encounter excludes pharmaceutical or biologicals not generally provided during a clinic visit. Refer to OAR 41-147-0120 Division Encounter and Recognized Practitioners.

(a) Because Division includes the costs of drugs or medication treatments administered by a clinic to treat a client during an office visit in the PPS all-inclusive encounter rate for the office visit, providers cannot bill separately for the costs of the drugs or treatments;

(b) Prescriptions are not included in the Prospective Payment System (PPS) encounter rate. To bill for filled prescriptions, the FQHC or RHC’s qualified enrolled pharmacy must bill Division using its pharmacy provider number.

(2) Clinics may directly bill Division using their clinic provider number for contraceptive supplies and contraceptive medications only for:

(a) Clients enrolled in a prepaid health plan (PHP): Clinics must bill the PHP first. If the PHP will not reimburse for the contraceptive supply or contraceptive medication, then the clinic can bill Division fee-for-service at the clinic’s acquisition cost. See also OAR 410-130-0585, Family Planning Services;

(b) Fee-for-service clients: Clinics can directly bill Division fee-for-service at the clinic’s acquisition cost for contraceptive supplies and contraceptive medications. See also OAR 410-130-0585, Family Planning Services.

(3) Refer to OAR 410 division 121, Pharmaceutical Services Program Rulebook for specific information.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0240
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0600
OMAP 39-2002, f. 9-13-02, cert. ef. 9-15-02
OMAP 42-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 19-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 8-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99

Or. Admin. R. 410-147-0320 Federally Qualified Health Center Rural Health Clinics Enrollment

(1) This rule outlines the Division of Medical Assistance Programs (Division) enrollment requirements for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) (Refer also to OAR 410-120-1260 and 943-120-0320, Provider Enrollment).

(a) For outpatient health programs or facilities operated by an American Indian tribe under the Indian Self-Determination Act (Public Law 93-638), providers should refer to the program rules for American Indian/Alaska Native (AI/AN) Services, OAR chapter 410, division 146, for enrollment details;

(b) An FQHC or RHC that operates a retail pharmacy; provides durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); or provides targeted case management (TCM) services, must enroll separately as a pharmacy, DMEPOS and/or TCM provider. For specific information, refer to OAR chapter 410, division 121, Pharmaceutical; OAR chapter 410, division 122, DMEPOS; and OAR chapter 410, division 138, TCM.

(c) A county Community Mental Health Program (CMHP) furnishing extended care services under contract with the Oregon Health Authority (Authority) Addictions and Mental Health Division (AMH) should refer to AMH for licensure and reimbursement requirements.

(2) To enroll with the Division as an FQHC, a health center must comply with one of the following:

(a) Receive Public Health Service (PHS) grant funds under the authority of Section 330;

(b) Have received FQHC Look-Alike designation from the Centers for Medicare and Medicaid Services (CMS), based on the recommendation of the Health Resources and Services Administration (HRSA)/Bureau of Primary Health Care (BPHC); or

(c) Be an Urban Indian Health Program (UIHP) clinic (under Title V of the Indian Health Care Improvement Act, Public Law 94-437). In the Omnibus Reconciliation Act (OBRA) of 1993, Title V programs were added to the list of specific programs automatically eligible for FQHC designation.

(3) Eligible FQHCs who want to enroll with the Division as an FQHC, and receive reimbursement under the Prospective Payment System (PPS) encounter rate methodology, must submit the following information:

(a) Completed Authority provider enrollment forms with attachments as required in OAR 943-120-0300 through 943-120-0320;

(b) National Provider Identifier (NPI) number and associated taxonomy code(s) obtained for the FQHC with the provider enrollment form (refer to OAR 943-120-0320);

(A) One each for medical, dental and mental health (including addiction, alcohol and chemical dependency) (see also OAR 410-147-0360);

(B) One for each FQHC-designated site, unless specifically exempted in writing by the Division to file a consolidated cost report (see also OAR 410-147-0340 Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)/provider numbers);

(d) Completed copy of the grant proposal submitted to HRSA/BPHC detailing the clinic’s service and geographic scope;

(e) Copy of the HRSA Notice of Grant Award Authorization for Public Health Services Funds under Section 330, or a copy of the letter from CMS designating the facility as a “Look Alike” FQHC;

(f) A copy of the clinic’s trial balance (see OAR 410-147-0500, Total Encounters for Cost Reports);

(g) Audited financial statements (refer to OAR 410-120-1380 Compliance with Federal and State Statutes, and Office of Management and Budget Circular A-133 entitled “Audits of States, Local Governments and Non-Profit Organizations”);

(h) Depreciation schedules;

(i) Overhead cost allocation schedule;

(j) A copy of the clinic’s AMH certification for a program of mental health services if someone other than a licensed psychiatrist, licensed clinical psychologist, licensed clinical social worker, psychiatric nurse practitioner, licensed professional counselor or licensed marriage and family therapist is providing mental health services;

(k) A copy of the clinic’s AMH letter or licensure of approval if providing Addiction, Alcohol and Chemical Dependency services;

(l) A list of all Prepaid Health Plan (PHP) contracts;

(m) A list including names and NPI numbers of individual practitioners enrolled with the Division and contracted with or employed by the FQHC; and

(n) A list including business names, addresses and facility NPI numbers for all Division-enrolled clinics affiliated or owned by the FQHC including any clinics that do not have FQHC status.

(4) For enrollment with the Division as an RHC, a clinic must:

(a) Be designated by CMS as an RHC.

(b) Maintain Medicare certification and be in compliance with all Medicare requirements for certification.

(5) Eligible RHCs who want to enroll with the Division as an RHC, and be eligible for payment under the Prospective Payment System (PPS) encounter rate methodology, must submit the following information:

(a) Completed the Authority provider enrollment forms with attachments as required in OAR 943-0120-0300 through 943-120-0320;

(b) National Provider Identifier (NPI) number and any associated taxonomy codes obtained for the RHC with the provider enrollment form (refer to OAR 943-120-0320);

(d) Medicare Cost Report for RHC or completed Cost Statement(s) (DMAP 3027) (see OAR 410-147-0360). Complete a cost statement for each RHC-designated site, unless specifically exempted in writing by the Division to file a consolidated cost report (see OAR 410-147-0340):

(A) The Division will accept an uncertified Medicare Cost Report;

(B) If the clinic’s Medicare Cost Report, provided to the Division, does not include all covered Medicaid costs provided by the clinic, the clinic must submit additional cost information. The Division will include these costs when determining the PPS encounter rate;

(e) A copy of the clinic’s trial balance (see OAR 410-147-0500, Total Encounters for Cost Reports only if completing Cost Statement DMAP 3027);

(f) Audited financial statements (refer to OAR 410-120-1380 Compliance with Federal and State Statutes, and Office of Management and Budget Circular A-133 entitled “Audits of States, Local Governments and Non-Profit Organizations” if completing Cost Statement DMAP 3027);

(g) Depreciation schedules (only if completing Cost Statement DMAP 3027);

(h) Overhead cost allocation schedules (only if completing Cost Statement DMAP 3027);

(i) A copy of the clinic’s AMH certification for a program of mental health services if someone other than a licensed psychiatrist, licensed clinical psychologist, licensed clinical social worker, psychiatric nurse practitioner, licensed professional counselor or licensed marriage and family therapist is providing mental health services;

(j) A copy of the clinic’s AMH letter or licensure of approval if providing Addiction, Alcohol and Chemical Dependency services;

(k) A list of all Prepaid Health Plan (PHP) contracts;

(l) A list including names and NPI numbers of individual practitioners enrolled with the Division and contracted with or employed by the RHC; and

(m) A list including business names, addresses and facility NPI numbers for all Division-enrolled clinics affiliated or owned by the RHC including any clinics that do not have RHC status.

(6) The FQHC/RHC Program Manager, upon receipt of the required items as listed in section (3) of this rule for FQHCs and Section (5) of this rule for RHCs, will review all documents for compliance with program rules, completeness and accuracy.

(7) The Division prohibits an established, enrolled FQHC or RHC that adds or opens a new clinic site from submitting claims for services rendered at the new site under their FQHC or RHC Division enrollment, and according to the PPS encounter rate, prior to the Division’s acknowledgment. An FQHC or RHC is required to immediately submit to the attention of the FQHC/RHC Program Manager, Division:

(a) For FQHCs only, a copy of the recent HRSA Notice of Grant Award including the new site under the main FQHC’s scope;

(b) For RHCs only, a copy of Medicare’s letter certifying the new clinic as an RHC;

(d) A recent list of names and NPI numbers for all individual practitioners enrolled with the Division and contracted with or employed by the new FQHC or RHC site.

(8) If an established and enrolled RHC or FQHC changes ownership, the new owner must submit:

(a) Cost Statement (DMAP 3027) or Medicare Cost Report within 30 days from the date of change of ownership to have a new PPS encounter rate calculated; or in writing, a letter advising adoption of the PPS encounter rate calculated under the former ownership (see OAR 410-147-0360);

(b) Notice of a change in tax identification number;

(d) A recent list of names and NPI numbers for all individual practitioners enrolled with the Division and contracted with or employed by the FQHC or RHC; and

(e) A recent list including business names, addresses, NPI numbers and associated taxonomy codes for all Division-enrolled clinics affiliated or owned by the FQHC or RHC including any clinics that do not have FQHC or RHC status.

(9) FQHCs that are involved with a sub-recipient must provide documentation. Sub-recipient contracts with an FQHC must enroll as an FQHC and submit the same required documentation as outlined under the enrollment sections of this rule.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 38-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 47-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 44-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0010
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
HR 13-1993, f. & cert. ef. 7-1-93
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91

Or. Admin. R. 410-147-0340 Federally Qualified Health Centers and Rural Health Clinics Provider Numbers

(1) Pursuant to National Provider Identifier (NPI) requirements in 45 CFR Part 162 providers must use a NPI, and in specific situations associated taxonomy code(s), when billing the Division of Medical Assistance Programs (Division).

(2) A Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) shall register the NPI number and associated taxonomy code, obtained for the FQHC or RHC at the time of enrollment. Multiple sites are not separately enrolled, unless each site has a different tax identification number.

(3) The Division may grant an exception to section (2) of this rule upon written request to the Division of Medical Assistance Programs — Attn: FQHC/RHC Program Manager. The request must include a detailed explanation describing the:

(a) Need for separate enrollment of an additional site; and

(b) Mechanisms in place to assure no duplication of billings.

(4) If the Division finds evidence of duplicate or inappropriate billing resulting from provider misuse under multiple enrollments, the Division may terminate the exception upon written notice to the clinic.

(5) If the Division grants an exception to section (2) of this rule, the Division shall separately enroll each clinic site. When granted multiple provider enrollments, clinics must register:

(a) A separate NPI number for each clinic; or

(b) One NPI number and separate taxonomy codes for each clinic.

(6) If an FQHC or RHC has several clinic sites and one or more of the clinics are not designated as an FQHC or RHC, the non-FQHC or non-RHC (each individual clinic) must:

(a) Enroll as a billing provider; and

(b) Each practitioner must individually enroll.

(7) Upon enrollment and each October thereafter, FQHCs and RHCs must submit to the Division:

(a) A list including names and NPI numbers of individual practitioners associated with the FQHC/RHC; and

(b) A list including business names, addresses and facility NPI numbers for all Division-enrolled clinics affiliated or owned by the FQHC or RHC including any clinics that do not have FQHC or RHC status

(8) An FQHC or RHC that operates a retail pharmacy, provides durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS), must enroll separately as a pharmacy and/or DMEPOS provider. Refer to OAR chapter 410, division 121, Pharmaceutical and OAR chapter 410, division 122, DMEPOS; for specific information. These services are not billed under FQHC or RHC enrollment.

(9) The Division shall coincide registration of a clinic’s NPI number and associated taxonomy codes if applicable, effective the date of enrollment with the Division as an FQHC or RHC, and after the encounter rate is established.

(10) Prepaid Health Plans (PHP) are required to report all PHP encounters using the FQHC/RHC’s NPI and associated taxonomy code, if required, and not individual practitioner NPI numbers and taxonomy codes.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 8-2011, f. 6-6-11, cert. ef. 7-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-147-0360 Encounter Rate Determination

(1) The Division of Medical Assistance Programs (Division) will coincide enrollment of a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) with the calculation of a clinic’s Prospective Payment System (PPS) encounter rate:

(a) DMAP will enroll a clinic as an FQHC or RHC effective the date DMAP determines the clinic’s PPS encounter rate. The encounter rate may be used to bill for services provided on or after the coinciding effective dates of enrollment as an FQHC or RHC with the Division and determination of the clinic’s encounter rate.

(b) Consistent with OAR 410-120-1260, Provider Enrollment, only enrolled providers can submit claims to the Division for providing specific care, item(s), or service(s) to Division clients. A clinic or individual provider needs to bill fee-for-service for services provided prior to enrollment as an FQHC or RHC with DMAP, according to applicable service program’s enrollment and billing Oregon Administrative Rules (OARs).

(2) To determine the PPS encounter rate(s), an FQHC must submit all financial documents listed in OAR 410-147-0320 for each Medical, Dental and Mental Health/Substance Use Disorder Services.

(a) Effective October 1, 2004, for FQHCs only, the Division will calculate three separate PPS encounter rates for clinics newly enrolling as an FQHC with the Division:

(i) Medical;

(ii) Dental; and

(iii) Mental Health/Substance Use Disorder services.

(b) FQHCs enrolled with the Division prior to October 1, 2004, with a single PPS medical encounter rate, will have a separate encounter rate calculated if the clinic adds a service category listed in either Section (2)(a)(ii) or (iii) of this rule. Refer also to Section (16) of this rule.

(3) To determine the PPS encounter rate, a RHC must submit all financial documents listed in OAR 410-147-0320.

(a) The Division will accept an uncertified Medicare Cost Report;

(b) If the clinic’s Medicare Cost Report, provided to the Division, does not include all covered Medicaid costs provided by the clinic, the clinic must submit additional cost information. The Division will include these costs when determining the PPS encounter rate.

(c) The Division will remove the Medicare productivity screen and any other Medicare payment caps from the RHC’s Medicare encounter rate;

(d) An RHC can submit the Division cost statement form 3027 as a substitute to the Medicare Cost Report.

(4) FQHCs or RHCs that have an additional clinic site(s) under the main FQHC or RHC designation, must file the required financial documentation for each clinic site unless specifically exempted in writing by the Division. If exempted from this requirement by the Division, an FQHC or RHC may file a consolidated cost report. See OAR 410-147-0340 regarding separate enrollment for multiple sites.

(5) FQHCs and RHCs cannot include costs associated with non-FQHC or non-RHC designated sites in the cost report.

(6) FQHCs and RHCs cannot include costs associated with non-covered Medicaid services. The Division does not allow the inclusion of indirect or direct costs for non-covered Medicaid services in the clinic’s cost report/statement as allowed expenses. Refer to OAR 410-120-1200 Excluded Services and Limitations.

(7) An out-of-state FQHC or RHC will only include expenses associated with Medicaid covered services provided at clinic sites serving Division clients when completing the Cost Statement (DMAP 3027). For RHCs only, the Medicare Cost Report can only include financial documents for Medicaid-covered services provided at clinic sites that see Division clients. Do not include costs associated with non-FQHC or RHC designated sites, or clinic sites that do not serve Division clients in the Cost Statements (DMAP 3027) or Medicare Cost Reports for RHCs.

(8) At any time, if the Division determines that the costs provided by the clinic for calculating the PPS encounter rate(s) were inflated, the Division may:

(a) Request corrected cost reports and any other financial documents in order to review and adjust the encounter rate(s); and

(b) Impose sanctions as defined in OARs 410-120-1400 Provider Sanctions, 410-120-1460 Type and Conditions of Sanctions; and 943-120-0360 Consequences of Non-Compliance and Provider Sanctions.

(9) Effective January 1, 2001, DMAP determines FQHC and RHC encounter rates in compliance with 42 USC 1396a(bb). In general, the PPS encounter rate is calculated by dividing total costs of Medicaid covered services furnished by the FQHC/RHC during fiscal years 1999 and 2000 by the total number of clinic encounters during the two fiscal years.

(10) Clinics existing in 1999 and 2000, and enrolled with the Division as a FQHC or RHC as of January 1, 2001, receive payment from the Division for services rendered to Medicaid-eligible OHP clients per an all-inclusive PPS encounter rate (calculated on a per visit basis) that is equal to 100 percent of the average of the costs of the clinic for furnishing such services during fiscal years 1999 and 2000 which are reasonable and related to the cost of furnishing such services, or based on such other tests of reasonableness.

(11) Clinics first qualifying as an FQHC or RHC after fiscal year 2000, will receive payment from the Division for services rendered to Medicaid-eligible OHP clients per an all-inclusive PPS encounter rate (calculated on a per visit basis) that is equal to 100 percent of the average of the costs of the clinic for furnishing such services during the fiscal year the clinic first qualifies as an FQHC or RHC. Coinciding with enrollment as an FQHC or RHC with the Division, a clinic will have a PPS encounter rate:

(a) Established by reference to payments to other clinics located in the same or adjacent areas, and of similar caseload; or

(b) In the absence of such clinic, through cost reporting methods based on tests of reasonableness.

(12) Beginning in fiscal year 2002, and for each fiscal year thereafter, each FQHC/RHC is entitled to the PPS encounter rate(s) payment amount to which the clinic was entitled under Section 42 USC 1396a(bb) in the previous fiscal year, increased by the percentage increase in the Medicare Economic Index (MEI).

(13) For established, enrolled clinics with a change of ownership, the new owner can submit:

(a) A Cost Statement (DMAP 3027) or Medicare Cost Report within 30 days from the date of change of ownership for review by the Division to determine if a new PPS encounter rate will be calculated as otherwise described in this rule; or

(b) In writing, a letter advising adoption of the PPS encounter rate calculated under the former ownership, including notice if there is a change to the clinic’s tax identification number;

(c) Failure to submit a cost statement (DMAP 3027) or Medicare Cost Report within 30 days of the change of ownership, will forfeit the opportunity for calculation of a PPS encounter rate(s) at a later date. The PPS encounter rate(s) calculated under the former ownership will be reassigned to the new ownership.

(14) The Centers for Medicare and Medicaid Services (CMS) defines a change in scope of services as one that affects the type, intensity, duration, and amount of services. Clinics must submit a request for change in scope to the Division for review.

(15) The Division may establish a separate PPS encounter rate if a FQHC adds Dental or Mental Health/Substance Use Disorder services. A separate PPS encounter rate will be calculated by the Division for the added service element if:

(a) Costs associated with the added service element were not included on the original cost statements for the initial PPS encounter rate determination;

(b) The addition of the service element has been approved by the Health Resources and Services Administration (HRSA) and is included in the notice of grant award issued by HRSA;

(c) The FQHC is certified by the Addictions and Mental Health Division (AMH) to provide mental health services (if mental health services are provided by un-licensed providers), or has a letter or licensure of approval by Addictions and Mental Health Division (AMH) former Office of Mental Health and Addictions Services (OMHAS) to provide substance use disorder services;

(i) Certification by AMH of an FQHC’s outpatient mental health program is required if mental health services are provided by non-licensed providers. Refer to OAR 410-147-0320(3)(i) and (5)(h) for certification requirements

(iii) A letter of licensure or approval by AMH is required for FQHCs providing substance use disorder services. Refer to OAR 410-147-0320 (3)(j) and (5)(i);

(16) If an FQHC meets the criteria as outlined in Section (15) of this rule for the addition of Dental or Mental Health/Substance Use Disorder services, after the initial encounter rate determination, the Division will determine the PPS encounter rate for the newly added service element using the date the scope change was approved by HRSA. For example: the clinic submitted 1999 & 2000 cost reports. In 2001 the clinic added a dental clinic. The cost report would be from 2001 (the most appropriate months) with the MEI adjusted for 2002, 2003 and 2004.

(17) When an FQHC shares the same space for multiple services, then the Division will use square footage to determine the percent of the indirect cost associated with each encounter rate.

(18) A clinic may be exempt from this requirement if an FQHC has minimal utilization for a particular service such as “Look Alike” clinics and is located in an isolated area. Submit an exemption request with appropriate documentation to the Division FQHC Program Manager for consideration.

(19) For an FQHC approved by the Division to participate in an Alternate Payment Methodology (APM) pilot, the following will apply:

(a) APM converts the clinics current PPS rate into an equivalent per member per month (PMPM) rate using the clinic’s historical patient utilization and the clinic’s PPS cost base rate. The purpose of APM is to reimburse clinics an amount no less than what the clinic would have received if paid with PPS. The Division shall process quarterly reconciliations and if the APM issued is less than what the clinic would have received if paid using PPS, the Division shall reimburse the clinic the difference. The Division will perform a final annual reconciliation and remit payment within 120 days after the close of the calendar year.

(b) The Division shall have a memorandum of understanding to establish an effective date with each participating clinic.

(c) A clinic may request to return to its PPS rate by submitting written request to the Division. The Division shall return the clinic to their PPS rate within 30 business days after a clinics request has been received.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 45-2013, f. & cert. ef. 8-26-13
DMAP 8-2013(Temp), f. & cert. ef. 3-1-13 thru 8-27-13
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-147-0362 Change in Scope of Services

(1) As required by 42 USC § 1396a(bb)(3)(B), the Division of Medical Assistance Programs (Division) must adjust Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) Prospective Payment System (PPS) encounter rates based on any increase or decrease in the scope of FQHC or RHC services, as defined by 42 USC § 1396d(a)(2)(B)–(C).

(2) The Centers for Medicare and Medicaid Services (CMS) defines a “change in scope of services” as one that affects the type, intensity, duration, and/or amount of services provided by a health center. CMS’ broad definition of change in scope of services allows the Division the flexibility to develop a more precise definition of what qualifies as a change in scope as it relates to the elements “type,” “intensity,” “duration,” and “amount” and procedures for implementing these adjustments. This rule defines the Division’s policy for implementing FQHC and RHC PPS rate adjustments based on a change in scope of services.

(3) A change in the scope of FQHC or RHC services may occur if the FQHC or RHC has added, dropped or expanded any service that meets the definition of an FQHC or RHC service as defined by 42 USC § 1396d(a)(2)(B)–(C).

(4) A change in the cost of a service is not considered in and of itself a change in the scope of services. An FQHC or RHC must demonstrate how a change in the scope of services impacts the overall picture of health center services rather than focus on the specific change alone. For example, while health centers may increase services to higher-need populations, this increase may be offset by growth in the number of lower intensity visits. Health centers therefore need to demonstrate an overall change to health centers’ services.

(5) The following examples are offered as guidance to FQHCs and RHCs to facilitate understanding the types of changes that may be recognized as part of the definition of a change in scope of services. These examples should not be interpreted as a definitive nor comprehensive delineation of the definition of scope of service. Examples include:

(a) A change in scope of services from what was initially reported and incorporated in the baseline PPS rate. Examples of eligible changes in scope of services include, but are not limited to:

(A) Changes within medical, dental or mental health (including addiction, alcohol and chemical dependency services) service areas (e.g. vision, physical/occupation therapy, internal medicine, oral surgery, podiatry, obstetrics, acupuncture, or chiropractic);

(B) Services that do not require a face-to-face visit with an FQHC or RHC provider will be recognized (e.g. laboratory, radiology, case-management, supportive rehabilitative services, and enabling services.)

(b) A change in the scope of services resulting from a change in the types of health center providers. A change in providers alone without a corresponding change in scope of services does not constitute an eligible change. Examples of eligible changes include but are not limited to:

(A) A transition from mid-level providers (e.g. nurse practitioners) to physicians with a corresponding change in scope of services provided by the health center;

(B) The addition or removal of specialty providers (e.g., pediatric, geriatric or obstetric specialists) with a corresponding change in scope of services provided by the health center (e.g. delivery services);

(i) If a health center reduces providers with a corresponding removal of services, there may be a decrease in the scope of services;

(ii) If a health center hires providers to provide services that were referred outside of the health center, there may be an increase in the scope of services;

(c) A change in service intensity or service delivery model attributable to a change in the types of patients served including, but not limited to, homeless, elderly, migrant, or other special populations. A change in the types of patients served alone is not a valid change in scope of services. A change in the type of patients served must correspond with a change in scope of services provided by the health center;

(d) Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the health center services, including new or expanded service facilities. A change in capital expenditures must correspond with a change in scope of services. (e.g. the addition of a radiology department);

(e) A change in applicable technologies or medical practices:

(A) Maintaining electronic medical records (EMR);

(B) Updating or replacing obsolete diagnostic equipment (which may also necessitate personnel changes); or

(f) A change in overall health center costs due to changes in state or federal regulatory or statutory requirements. Examples include but are not limited to:

(A) Changes in laws or regulations affecting health center malpractice insurance;

(B) Changes in laws or regulations affecting building safety requirements; or

(6) The following changes do not qualify as a change in scope of service, unless there is a corresponding change in services as described in sections (3)–(5):

(a) A change in office hours;

(b) Adding staff for the same service-mix already provided;

(d) A change in office location or office space; or

(e) A change in the number of patients served.

(7) Threshold change in cost per visit: To qualify for a rate adjustment, changes must result in a minimum 5% change in cost per visit. This minimum threshold may be met by changes that occur over the course of several years (e.g. health centers would use the cost report for the year in which all changes were implemented and the 5% cost/visit was met, as described in sections (13) and (14) of this rule). A change in the cost per visit is not considered in and of itself a change in the scope of services. The 5% change in cost per visit must be a result of one or more of the changes in the scope of services provided by a health center, as defined in sections (3)–(5) of this rule. The intent of this threshold is to avoid administrative burden caused by minor change in scope adjustments.

(8) If a FQHC or RHC has experienced an increase or decrease in the health center’s scope of services, as described in sections (3)–(5) of this rule and that meets the threshold requirement of section (7) of this rule, the FQHC or RHC must submit to the Division a written application as outlined below. The Division may also initiate a review of whether a change in scope of services has occurred at a health center:

(a) A written narrative describing the specific changes in health center services, and how these changes relate to a change in the health center’s overall picture of services;

(b) An estimate of billable Medicaid encounters for the forthcoming 12-month period so the financial impact to the Division can be accounted for;

(c) A cost statement. All costs and expenses reported must be in agreement with the principles of reasonable cost reimbursement as found at 42 CFR 413, Centers for Medicare and Medicaid Services Publication 15-1 (Provider Reimbursement Manual), and any other regulations mandated by the Federal government. Any situations not covered will be based on Generally Accepted Accounting Principals (GAAP). See Change in Scope Cost Report Instructions;

(d) Certification by the Addiction and Mental Health Division (AMH) of a health center’s outpatient mental health program is required if mental health services are provided by non-licensed providers. Refer to OAR 410-147-0320(3)(i) and (5)(h) for certification requirements; and

(e) A letter of licensure or approval by AMH is required for health centers providing addiction, alcohol and chemical dependency services. Refer to OAR 410-147-0320(3)(j) and (5)(i); and

(f) The clinic is responsible for providing complete and accurate copies of the above documentation. Health centers may submit a maximum of one change in scope application per year.

(9) Upon receipt of a health center’s written change in scope of services request, the FQHC/RHC Program manager will:

(a) Review all documents for completeness, accuracy and compliance with program rules. An incomplete application will result in a delay in the Division’s review until the complete application is received; and

(b) Respond to the health center with a decision within 90 days of receipt of a complete application.

(10) Providers may appeal this decision in accordance with the provider appeal rules set forth in OAR 410-120-1560.

(11) Approved change in scope of service requests will result in PPS rate adjustments:

(a) A separate mental health or dental PPS encounter rate will be calculated if a FQHC or RHC adds dental or mental health (including addiction, and alcohol and chemical dependency) services, and costs associated with these service categories were not included in the original cost statements used to determine the baseline PPS encounter rate;

(b) If costs associated with dental or mental health services were included in the original cost statements, whether negligible or significant, health centers have the option of having an adjusted single encounter rate, or requesting a separate dental or mental health rate.

(12) The new rate will be effective beginning the first day of the quarter immediately following the date the Division approves the change in scope of services adjustment (e.g. January, April, July, or October 1):

(a) The Division will not implement adjusted PPS rates (for qualifying change in scope of service requests) retroactive to the date a change in scope of services was implemented by the health center;

(b) It is a health center’s responsibility to request a timely change in scope of service rate adjustment.

(13) For changes occurring on or after October 1, 2008, the effective date of this policy, FQHCs and RHCs are required to:

(a) For anticipated changes, health centers should submit prospective costs for the Division to calculate a new per visit rate. These costs will be based on reasonable cost projections and reviewed by the Division. Health centers may later request a subsequent rate adjustment based on actual costs;

(b) For gradual or unanticipated changes, health centers must provide at least six months of actual costs beginning the date on which the change in the cost per visit threshold is met, or beginning in the calendar year of the FQHC/RHC’s fiscal year in which the changes were implemented and the cost threshold was met. For example, a health center implements a change in scope of services in 2008, but the additional costs incurred do not meet the 5% threshold criteria. In 2009 the health center implements additional scope of service changes. Additional costs incurred in 2009 together with the costs incurred for 2008 meet the 5% threshold. The health center would report costs for 2009;

(c) Health centers may submit both actual costs (for prior changes) as well as projected costs (for anticipated changes). Prior to submitting both actual and projected costs, health centers should work with the Division’s FQHC/RHC Program manager to confirm the appropriate time periods of costs to submit.

(14) For changes that occurred prior to the effective date of this policy, October 1, 2008, FQHCs and RHCs are required to:

(a) Submit cost reports for either:

(A) The first year of actual costs beginning the date on which a change in the cost per visit threshold is met; or

(B) The calendar year or the FQHC/RHC’s fiscal year in which the changes were implemented and the cost threshold was met;

(b) For changes that occurred over multiple and overlapping time periods, FQHC/RHCs will submit actual costs for the time period beginning when all changes were in effect. For example, if changes occurred in 2003 and 2004, health centers would submit their 2004 cost report that would include costs for changes implemented in both 2003 and 2004;

(c) Rate adjustments calculated using costs from prior fiscal years will be adjusted by the Medicare Economic Index (MEI) to present.

(15) FQHC and RHCs clinics that choose to participate in the Patient Centered Primary Care Home (PCPCH) Program must meet the requirements and adhere to rules outlined in OAR 409-055-0000 through 409-055-0080 and 410-141-0860, Oregon Health Plan Primary Care Manager and Patient Centered Primary Care Home Provider Qualification and Enrollment:

(a) The PCPCH Program is outside the Prospective Payment system. Providers who choose to participate and meet all related requirements shall receive a separate payment per the PMPM payment established by OAR 410-141-0860;

(b) If a provider has a PPS rate that includes costs for operating a medical home or health home but would like to participate as a PCPCH, then they must submit a change in scope for a change in service delivery method.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042, 414.065 & 413.032
Statutes/Other Implemented: ORS 414.065 & 413.032
DMAP 14-2012, f. & cert. ef. 3-22-12
DMAP 28-2011, f. 9-30-11, cert. ef. 10-1-11
DMAP 10-2007, f. 6-14-07, cert. ef. 7-1-07

Or. Admin. R. 410-147-0365 Rural Health Clinic Obstetrics Care Delivery Procedures Reimbursement

Reimbursement for obstetric delivery procedures by the Division of Medical Assistance Programs (Division) to eligible Medicare-certified Independent RHCs will be according to the physician fee schedule and outside of the Prospective Payment System (PPS).

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 20-2010, f. 6-23-10, cert. ef. 7-1-10
DMAP 9-2010(Temp), f. 4-13-10, cert. ef. 5-1-10 thru 10-26-10
DMAP 20-2007, f. 12-5-07, cert. ef. 1-1-08
OMAP 44-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 64-2005, f. 11-29-05, cert. ef. 1-1-06
OMAP 48-2005(Temp), f. & cert. ef. 9-15-05 thru 2-15-06
OMAP 26-2005, f. 4-20-05, cert. ef. 6-1-05
OMAP 18-2005(Temp), f. 3-15-05, cert. ef. 3-18-05 thru 9-1-05

Or. Admin. R. 410-147-0380 Accounting and Record Keeping

(1) General Requirements:

(a) The following rules and regulations apply to clinics reimbursed under the Federally Qualified Health Center (FQHC) and Rural Health Clinic Program;

(b) In cases of conflict between the rules contained in section (2) and (3) of this rule, section (2) will prevail over section (3);

(c) FQHCs and RHCs must use the cost principles contained in Office of Management and Budget (OMB) Circular A-87 or A-122 to determine reasonable costs. Use the circular appropriate to your clinic;

(d) Must adhere to acceptable accounting standards.

(2) Rules and Regulations:

(a) FQHC and RHC Administrative Rules;

(b) The Division of Medical Assistance Programs (Division) General Rules;

(d) All other applicable Division provider rules.

(3) Cost Principles for State and Local Governments, OMB Circular A-87 and A-122.

(4) Each FQHC and RHC shall:

(a) Maintain internal control over and accountability for all funds, property and other assets;

(b) Maintain complete client documentation;

(d) Adequately safeguard all such assets and assure that they are used solely for authorized purposes;

(e) Prepare Cost Statements (Division 3027) or Medicare Cost Reports for RHCs in conformance with:

(A) Generally accepted accounting principles;

(B) The provisions of the FQHC and RHC Administrative Rules; and

(f) Maintain for a period of not less than five years from the end of the fiscal the year:

(A) Cost Statement (Division 3027) or Medicare Cost Report for RHCs;

(B) Cost Statement Worksheet (Division 3032);

(D) Audited financial statements;

(E) Depreciation schedules;

(F) Overhead cost allocation schedules; and

(G) Financial and clinical records for the period covered by the Cost Statement (Division 3027) or Medicare Cost Report for RHCs.

(g) Maintain adequate records to thoroughly explain how the amounts reported on the Cost Statement (Division 3027) were determined. If there are unresolved audit questions at the end of the five-year period, the records must be maintained until the questions are resolved;

(h) Adequately document expenses reported as allowable costs in the records of the clinic or they will be disallowed. Documentation for travel and education expenses must include a summary of costs for each employee stating the purpose of the trip or activity, the dates, name of the employee, and a detailed breakdown of expenses. Receipts must be attached for expenses over $25;

(i) Prepare special work papers or reports to support or explain data reported on the Cost Statement (Division 3027) or Medicare Cost Report for RHCs for current or previous periods at Division's request. These work papers/reports must be completed within 30 days of the Division request. An extension of up to 30 days may be granted if the request is made before the end of the original 30 day period. Extensions must be requested in writing;

(j) Ensure that the Cost Statement (Division 3027) or Medicare Cost Report for RHCs is reconcilable to the audited financial records and encounters must be reconcilable to the Uniform Data Set (UDS) form or other reasonable data Division may request. If the Cost Statement (Division 3027) or Medicare Cost Report for RHCs cannot be reconciled, the UDS numbers will be used or other appropriate data sets as determined by Division;

(k) Do not submit financial documentation to Division for FQHC or RHC sites that:

(A) Are not designated as an FQHC or RHC, and/or;

(B) Do not serve Medical Assistance Program clients.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0080
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
HR 7-1995, f. 3-31-95, cert. ef. 4-1-95
HR 13-1993, f. & cert. ef. 7-1-93
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91

Or. Admin. R. 410-147-0400 Compensation for Outstationed Outreach Activities

(1) This rule provides reasonable compensation for activities directly related to the receipt and initial processing of applications for individuals, including low-income pregnant women and children, to apply for Medicaid at outstation locations other than state offices.

(2) A federally qualified health center (FQHC) eligible in accordance with OAR 410-120-0045, will be eligible for compensation under this rule.

(3) ‘‘Initial processing’’ includes the following activities:

(a) Taking applications;

(b) Assisting applicants in completing the application;

(d) Obtaining required documentation to complete processing of the application;

(e) Ensuring that the information contained on the application form is complete; and

(f) Conducting any necessary interviews.

(4) “Initial processing” does not include evaluating the information contained on the application and the supporting documentation or making a determination of eligibility or ineligibility.

(5) At locations that are infrequently used by the designated low-income eligibility groups, the Division may use the following resources:

(a) Volunteers, provider or contractor employees; or

(b) Its own eligibility staff, or

(A) The FQHC as outlined in section (12); or

(B) Prominently displaying a notice that includes the telephone number for the state OHP Application Center or the local branch office that applicants may call for assistance.

(6) Eligible FQHCs may be able to receive reasonable compensation for outreach activities performed by Outstationed Outreach Workers (OSOW) that is equal to 100% of direct costs.

(7) Allowable direct cost expenses for OSOW reimbursement include:

(a) Travel expenses incurred by the FQHC for Division training on OSOW activities;

(b) Phone bills, if a dedicated line is used. Otherwise an estimate of telephone usage and resulting costs;

(A) Wages shall be the lesser of:

(i) Wages reported by the FQHC; or

(ii) Wages paid by the State of Oregon to an employee of the state providing enrollment assistance to individuals applying for OHP;

(iii) Wage reimbursement may not exceed the highest salary issued by the State of Oregon to a Human Services Specialist 2;

(B) Taxes;

(D) Premiums paid by the FQHC for private health insurance.

(d) Reasonable costs for equipment necessary to perform outreach activities, which does include expenses for replacing equipment if the original equipment cost was reported on the cost statement when the clinic’s initial PPS encounter rate was calculated;

(e) Rent or space costs only if 100% of facility costs were not reported on the cost statement when the clinic’s initial PPS encounter rate was calculated;

(f) Reasonable office supplies necessary to perform outreach activities; and

(g) Postage.

(8) The Division may not include indirect costs in the OSOW reimbursement rate. Indirect costs include but are not limited to the following:

(a) Any costs included in the initial calculation of a clinic’s PPS encounter rate;

(b) Contracted interpretation services;

(d) Supervision costs; and

(e) Operating expenses including utilities, building maintenance and repair, and janitorial services.

(9) Clinics must submit to the Division a cost statement for the preceding calendar year between October 1, and October 31, of each year for Division review and approval of the clinic’s OSOW direct costs.

(10) If a clinic fails to submit the OSOW cost statement by October 31 of the required year, the clinic may not be eligible for reimbursement of OSOW costs as of January 1 for the following year.

(11) Any change to the OSOW rate, based on the October cost statement submission, shall be effective January 1 of the following year; The Division shall make payment to the clinic for the reviewed and accepted OSOW costs in four equal installments at the beginning of each calendar quarter; January 1, April 1, July 1, and October 1.

(12) Clinic locations with limited operating hours, or that limit access to the general public during their regular operating hours must calculate the actual time an OSOW meets face-to-face with the general public for receipt and the initial processing of applications. For example, if a clinic employs an OSOW at a satellite school-based health center (SBHC), and the SBHC can only be accessed by the general public outside of the school’s normal hours of operation, use the percent of time an OSOW is available to meet face-to-face with potential applicants when reporting compensation as outlined in section (11)(c) of this rule.

(a) Clinics must display a notice in a prominent place that advises potential applicants when an OSOW will be available;

(b) The notice must include a telephone number that applicants may call for assistance.

(13) For staff employed by a clinic and performing outreach activities at less than full time, the clinic must calculate the percentage of time spent performing OSOW activities and maintain adequate documentation to support the time claimed. The percentage must be used to calculate personnel expenses incurred by an FQHC that are directly attributed to outreach activities performed by the employee. Outreach activities:

(a) May include assisting individuals with completing applications for other Department of Human Services (Department) and Authority-administered programs where eligibility is determined by staff at local branch offices;

(b) Does not include assisting individuals with applying for non-Department and non-Authority-administered programs.

(14) A clinic shall not claim reimbursement for costs associated with personnel positions where 100% of costs were included in the FQHC’s PPS encounter rate calculation.

(15) A Public Health Department designated as an FQHC or a School Based Health Center (SBHC) within the scope of an FQHC designation cannot participate in the Medicaid Administrative Claiming (MAC) program.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 35-2013, f. & cert. ef. 6-27-13
DMAP 9-2013(Temp), f. & cert. ef. 3-1-13 thru 6-29-13
DMAP 64-2012(Temp), f. 12-27-12, cert. ef. 1-1-13 thru 6-29-13
DMAP 8-2011, f. 6-6-11, cert. ef. 7-1-11
DMAP 47-2009, f. 12-15-09, cert. ef. 1-1-10
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0330
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
HR 13-1993, f. & cert. ef. 71-1-93

Or. Admin. R. 410-147-0420 Rebasing

(1) Determination of encounter rates effective January 1, 2001 as directed by the Balanced Budget Act (BBA) of 1997 and the Budget Refinement Act of 1999 Prospective Payment System (PPS) was changed for Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) clinics. PPS eliminates annual cost reports and retrospective settlements except for managed care organization (MCO) Supplemental Payments.

(2) As directed by the BBA and PPS, the federal government will notify states when clinics can re-base clinic rates. No specific date has been determined by the federal government at this time.

History

Statutory/Other Authority: ORS 413.042 & 414.065, 42 USC 1396a(bb) & CFR Title 42 Public Health
Statutes/Other Implemented: ORS 414.065
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-147-0440 Medicare Economic Index (MEI)

Effective January 1, 2001, as directed by the Balanced Budget Act of 1997, the Budget Refinement Act of 1999 Prospective Payment System (PPS), and BIPA all encounter rates must be adjusted annually by the Medicare Economic Index (MEI) for the current year. The encounter rate will be adjusted by the MEI effective January 1st of the current year.

History

Statutory/Other Authority: 413.042 & 414.065 42 USC 1396a(bb) & CFR Title 42 Public Health
Statutes/Other Implemented: ORS 414.065
OMAP 63-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-147-0460 Prepaid Health Plan Supplemental Payments

(1) Effective January 1, 2001, the Division of Medical Assistance Programs (Division) is required by 42 USC 1396a(bb), to make supplemental payments to eligible federally qualified health centers (FQHC) and rural health clinics (RHC) that contract with Prepaid Health Plans (PHP).

(2) The PHP Supplemental Payment represents the difference, if any, between the payment received by the FQHC/RHC from the PHP(s) for treating the PHP enrollee and the payment to which the FQHC/RHC would be entitled if they had billed Division directly for these encounters according to the clinic’s Medicaid Prospective Payment System (PPS) encounter rate. Refer to OAR 410-147-0360.

(3) In accordance with federal regulations the Provider must take all reasonable measures to ensure that in most instances Medicaid will be the payer of last resort. Providers must make reasonable efforts to obtain payment first from other resources before submitting claims to the PHP. Refer to OAR 410-147-0120(14).

(4) When any other coverage is known to the provider, the provider must bill the other resource(s) prior to billing the PHP. When a Provider receives a payment from any source prior to the submission of a claim to the PHP, the amount of the payment must be shown as a credit on the claim in the appropriate field. See also OAR 410-120-1280 Billing and 410-120-1340 Payment.

(5) Supplemental payment by Division for encounters submitted by FQHC/RHCs for purposes of this rule is reduced by any and all payments received by the FQHC/RHC from outside resources, including Medicare, private insurance or any other coverage. Therefore, FQHC/RHCs are required to report all payments received on the Managed Care Data Submission Worksheet, including:

(a) Medicaid PHPs;

(b) Medicare Advantage Managed Care Organizations (MCO);

(d) Any Third Party Resource(s) (TPR).

(6) Division will calculate the PHP Supplemental Payment in the aggregate of the difference between total payments received by the FQHC/RHC, to include payments as listed in Section (5) of this rule and the payment to which the FQHC/RHC would have been eligible to claim as an encounter if they had billed Division directly per their PPS encounter rate.

(7) Effective July 1, 2006, FQHC/RHCs must submit their clinic’s data beginning with dates of service January 1, 2006 and after, using the Managed Care Data Submission Template developed by Division to report all PHP encounter and payment activity.

(8) To facilitate Division processing PHP supplemental payments, the FQHC or RHC must submit the following:

(a) To PHPs:

(A) Claims within the required timelines outlined in the contract with the PHP and in OAR 410-141-0420, Oregon Health Plan Prepaid Health Plan Billing Payment Under the Oregon Health Plan;

(B) The National Provider Identifier (NPI) number and associated taxonomy code, registered by the FQHC or RHC clinic with Division must be used when submitting all claims to the PHPs;

(b) To Division:

(A) Report total payments for all services submitted to the PHP:

(i) Including laboratory, radiology, nuclear medicine, and diagnostic ultrasound; and

(ii) Excluding any bonus or incentive payments;

(B) Report total payments for each category listed in the “Amounts Received During the Settlement Period” section of the Managed Care Data Submission Template Coversheet;

(C) Payments are to be reported at the detail line level on the Managed Care Data Submission Template Worksheet, except for capitated payments, or per member per month and risk pool payments received from the PHP;

(D) The total number of actual encounters. An encounter represents all services for a like service element (Medical, Dental, Mental Health, or Alcohol and Chemical Dependency) provided to an individual client on a single date of service. The total number of encounters is not the total number of clients assigned to the FQHC or RHC or the total detail lines submitted on the Managed Care Data Submission Template Worksheet;

(E) All individual NPI numbers and taxonomy codes assigned to practitioners associated with the FQHC or RHC. A practitioner associated with an FQHC or RHC can only retain individual active enrollment with Division in limited situations. Refer to OAR 410-147-0340(3).

(F) A current list of all PHP contracts. An updated list of all PHP contracts must be submitted annually to Division no later than October 31 of each year.

(9) PHP Supplemental Payment process:

(a) Division will process PHP Supplemental Payments on a quarterly basis:

(A) Quarterly processing of PHP Supplemental Payments includes a final reconciliation for the reported time period;

(B) For an FQHC or RHC approved by Division to participate in a pilot project, PHP Supplemental Payments will be processed at the discretion of Division in collaboration with health centers;

(b) Upon processing a clinic’s data and the PHP Supplemental Payment, Division will:

(A) Send a check to the clinic for PHP Supplemental Payment calculated from clinic data Division was able to process;

(B) Provide a cover letter and summary of the payment calculation; and

(c) The FQHC or RHC is responsible for reviewing the data Division was unable to process for accuracy and completeness. The clinic has 30 days, from the date of Division’s cover letter under Section (9)(b) of this rule, to make any corrections to the data and resubmit to Division for processing. Documentation supporting any and all changes must accompany the resubmitted data. A request for extension must be received by Division prior to expiration of the 30 days, and must:

(A) Be requested in writing;

(B) Accompanied by a cover letter fully explaining the reason for the late submission; and

(d) Within 30 days of Division’s receipt of the re-submitted data, Division will:

(A) Review the data and issue a check for all encounters Division verifies to be valid; and

(B) For quarterly data submissions, send a letter outlining the final quarterly settlement including any other pertinent information to accompany the check;

(e) The FQHC or RHC should submit data to Division within the timelines provided by Division.

(10) Clinics must carefully review in a timely fashion the data that Division was unable to process and returns to the FQHC or RHC. If clinics do not bring any incomplete, inaccurate or missing data to Division’s attention within the time frames outlined, Division will not process an adjustment.

(11) Division encourages FQHCs and RHCs to request PHP Supplemental Payment in a timely manner.

(12) Clinics must exclude from a clinic’s data submission for PHP supplemental payment, clinic services provided to a PHP-enrolled client when the clinic does not have a contract or agreement with the PHP. This may not apply to family planning services, or Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) prevention services. Family Planning and HIV/AIDS prevention services provided to a PHP-enrolled client when a clinic does not have a contract or agreement with the PHP:

(a) Must be reported in the clinic’s data submission for PHP Supplemental Payment if the clinic receives payment from the PHP;

(b) Cannot be reported in the clinic’s data submission for PHP Supplemental Payment if the clinic is denied payment by the PHP. If the PHP denies payment to the clinic, the clinic can bill these services directly to Division. (See also OAR 410-147-0060).

(13) If a PHP denies payment to an FQHC or RHC for all services, items and supplies provided to a client on a single date of service and meeting the definition of an “encounter” as defined in OAR 410-147-0120, for the reason that all services, items and supplies are non-covered by the plan, Division is not required to make a supplemental payment to the clinic. The following examples are excluded from the provision of this rule:

(a) Encounters that will later be billed to the PHP as a covered global procedure (e.g. Obstetrics Global Encounter);

(b) Had payment received by Medicare, and any other third party resource not have exceeded the payment the PHP would have made, the PHP would have made payment;

(14) If an FQHC or RHC has been denied payment by a PHP because the clinic does not have a contract or agreement with the PHP, Division is not required to make a supplemental payment to the clinic. Division is only required to make a PHP supplement payment when the FQHC or RHC has a contract with a PHP.

(15) Division will not reimburse some Medicaid covered services that are only reimbursed by PHPs, and are not reimbursed by Division. Division will not make PHP supplemental payment for these services, as Division does not reimburse these services when billed directly to Division.

(16) It is the responsibility of the FQHC or RHC to refer PHP-enrolled clients back to their PHP if the FQHC or RHC does not have a contract with the PHP, and the service to be provided is not family planning or HIV/AIDS prevention. The Provider assumes full financial risk in serving a person not confirmed by Division as eligible on the date(s) of service. See OAR 410-120-1140. It is the responsibility of the Provider to verify:

(a) That the individual receiving medical services is eligible on the date of service for the service provided; and

(b) Whether a client is enrolled with a PHP or receives services on an “open card” or “fee-for-service” basis.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 44-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02

Or. Admin. R. 410-147-0480 Cost Statement Instructions

(1) The Division of Medical Assistance Programs (Division) requires federally qualified health centers (FQHC) to submit Cost Statements (DMAP 3027).

(2) Rural health clinics (RHCs) can choose to submit either their Medicare Cost Report or the Cost Statement (DMAP 3027). If the RHC files a Medicare Cost Report, the Division may request additional information.

(3) The Division reimburses some services, items and supplies fee-for-service, outside of a FQHC or RHC’s Prospective Payment System (PPS) encounter rate. For this reason, clinics must exclude the costs for the following items from the cost statement:

(a) Contraceptive supplies and contraceptive medications (see OAR 410-147-0280);

(b) Pharmacy. Requires separate enrollment, refer to OAR chapter 410, division 121, Pharmaceutical Services Program Rulebook for specific information;

(c) Durable medical equipment and supplies. Requires separate enrollment, refer to OAR chapter 410, division 122, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS);

(d) Targeted case management (TCM) services. Requires separate enrollment, see OAR 410-147-0610, and refer to OAR chapter 410, division 138, Targeted Case Management for specific information; and.

(e) Comprehensive environmental lead investigation (refer to OAR 410-130-0245, Early and Periodic Screening, Diagnostic and Treatment Program).

(4) Payment for services provided by FQHCs and RHCs is in accordance with 42 USC 1396a (bb). In general, a Prospective Payment System (PPS) encounter rate is calculated on a per visit basis that is equal to the average of reasonable and allowable costs incurred by a clinic for furnishing services included in the State Plan under Title XIX and XXI of the Social Security Act. The rate is calculated by dividing the total costs incurred by an FQHC or RHC for furnishing services by the total number of clinic encounters as defined in OAR 410-147-0500. A clinic must submit a Cost Statement (DMAP 3027) to the Division:

(a) For established clinics during an adjustment to the clinic’s rate based on a change in scope of clinic services (see OAR 410-147-0360);

(b) For new clinics (see OAR 410-147-0360); or

(c) If there is a change of ownership, the new owner can submit the Cost Statement (DMAP 3027) or Medicare Cost Report within 30 days from the date of change of ownership to have a new PPS encounter rate calculated (see also OAR 410-147-0320 (8).

(5) The Cost Statement (DMAP 3027) must include all documents required by OAR 410-147-0320.

(6) Each section must be completed if applicable.

(7) Page 1 — Statistical Information:

(a) Enter the full name of the FQHC or RHC, the address and telephone number, the fiscal reporting period, legacy Division provider number, current National Provider Identifier (NPI) numbers and associated taxonomy code(s); the name of the persons or organizations having legal ownership of the FQHC or RHC; and all provider and health care practitioners as defined on the DMAP 3027 Cost Statement.

(b) The Cost Statement (DMAP 3027) must be prepared, signed and dated by both the FQHC or RHC accountant and an authorized responsible officer.

(8) Page 2 — Part A — FQHC or RHC Practitioner Staff and Visits:

(a) Full Time Equivalent (FTE) Personnel: List the total number of staff by position;

(b) Encounters: List the number of on-site and off-site encounters by staff (see OAR 410-147-0500, Total Encounters for Cost Reports). Exclude the following types of encounters from your total encounters:

(A) Out-stationed outreach workers;

(B) Administration; and

(C) Support staff, or any staff members who do not meet the criteria of OAR 410-147-0120(6) or the qualification or certification requirements under a clinic’s mental health certification or alcohol and other drug program approval or licensure by the Addictions and Mental Health Division (AMH) (see OAR 410-147-0320).

(9) Pages 3-4 — Reclassification and adjustment of trial balance of expenses:

(a) Record the expenses for covered health care costs, non-reimbursable program costs, allowable overhead costs, and non-reimbursable overhead costs:

(A) Covered health care (program) costs include all necessary and proper costs that are appropriate and helpful in developing and maintaining the operation of patient care facilities and activities. Necessary and proper costs related to patient care are usually costs which are common and accepted occurrences in the field of the provider's activity. Whether the Division allows the costs is subject to the regulations prescribing the treatment of specific items under the Medicaid program (see OAR 410-147-0020 Professional Services). Covered health care (program) and direct health care costs include but are not limited to:

(i) Personnel costs, including Medical record and medical receptionist costs;

(ii) Administrative costs;

(iii) Employee pension plan costs;

(iv) Normal standby costs;

(v) Medical practitioner salaries; and

(vi) Malpractice insurance costs;

(B) Non-reimbursable program costs are costs that are not related to patient care and which are not appropriate or necessary and proper in developing and maintaining the operation of patient care facilities and activities. Costs that are not necessary include costs that usually are not common or accepted occurrences in the field of the provider's activity. Non-reimbursable program costs include, but are not limited to:

(i) Women, Infants and Children (WIC);

(ii) Community services/housing projects (refer to OAR 410-120-1200);

(iii) Environmental external maintenance costs (e.g. landscaping, pesticide application);

(iv) Research;

(v) Public education; and

(vi) Outside services;

(C) Allowable overhead costs are those that have been incurred for common or joint objectives and cannot be readily identified with a particular final cost objective. Below are examples of overhead costs:

(i) Administrative costs;

(ii) Billing department expenses;

(iii) Audit costs;

(iv) Reasonable data processing expenses (not including computers, software or databases not used solely for patient care or clinic administration purposes);

(v) Space costs (rent and utilities); and

(vi) Liability insurance costs;

(D) Non-reimbursable overhead costs:

(i) Entertainment;

(ii) Fines and penalties;

(iii) Fundraising;

(iv) Goodwill;

(v) Gifts and contributions;

(vi) Political contributions;

(vii) Bad debts;

(viii) Other interest expense;

(ix) Advertising;

(x) Membership dues for public relations purposes, including country or fraternal club memberships;

(xi) Cost of personal use of motor vehicles;

(xii) Cost of travel incurred in connection with non-patient care related purposes; and

(xiii) Costs applicable to services, facilities, and supplies furnished by a related organization (related party transactions) in excess of the lower of cost to the related organization, or the price of comparable service as rendered by a non-related entity (see OAR 410-147-0540);

(b) Attach expense documentation from financial accounting records and an explanation for allocations, and allocation method used;

(c) Enter any reclassified expenses, adjustments (increase/decrease) of actual expenses in accordance with the FQHC and RHC administrative rules on allowable costs. A schedule of any reported reclassification of trial balance expense, whether an increase or decrease, must include:

(A) A reference to the line number on either page 3 or 4;

(B) A description of the reclassification or adjustment;

(D) The total for each debit and credit;

(d) Net expenses must equal the combined reclassified trial balance taking into account the adjustment amount on each detail line;

(e) Enter the totals from each column in the “Total” fields.

(10) Page 5 — Determinations — Determination of overhead applicable to FQHC and RHC services:

(a) Parts A and B: Enter all totals from the previous pages of the Cost Statement (DMAP 3027) as requested under overhead applicable to FQHC or RHC services and FQHC or RHC rate;

(b) Part C: If applicable, complete by entering the wages for Out-stationed Outreach Workers on line C1, divide the wages by the number of billable Division encounters to determine the rate per encounter (see also OAR 410-147-0400).

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 38-2010, f. 12-15-10, cert. ef. 1-1-11
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 44-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0400
HR 13-1993, f. & cert. ef. 7-1-93
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91

Or. Admin. R. 410-147-0500 Total Encounters for Cost Reports

(1) Federally Qualified Health Centers and Rural Health Clinics (FQHC/RHCs) are required to report the total number of encounters for furnishing services outlined in 42 USC 1396d(a)(2)(C) and 1396d(a)(2)(B), respectively.

(2) In general, the Division of Medical Assistance Programs (DMAP) calculates a FQHC or RHC's Prospective Payment System (PPS) encounter rate by dividing the total costs incurred by a clinic for furnishing services as defined in 42 USC 1396d(a)(2)(B) or (C) by the total number of all clinic visits, or "encounters." The intent of PPS is to calculate the average cost of an encounter, and not the average cost of a Medicaid billable encounter.

(3) This rule provides guidance for cost reporting of all encounters. It is the responsibility of the FQHC and RHC to report all encounters, except when expressly directed not to elsewhere in this rule. FQHCs and RHCs are required to include ALL:

(a) Encounters for all clients regardless of payor;

(b) Encounters for FQHC or RHC services that are not covered by Medicaid, Medicare, Third Party Payor or other party, but otherwise have an associated cost for providing the service whether billed to the client (e.g. uninsured, signed waiver on file) or absorbed by the clinic; and;

(c) Encounters regardless of line placement on the Health Evidence Review Commission's (HERC) Prioritized List of Health Services. For the purpose of reporting encounters according to this rule, encounters are not subject to the HERC Prioritized List, or service limitations and benefit reductions implemented by the Division of Medical Assistance Programs (DMAP).

(4) FQHCs and RHCs must report all encounters furnished to all client populations irrespective of coverage or payor source. Examples of client populations include, but are not limited to:

(a) Oregon Health Plan (OHP) clients (includes both fee-for-service and prepaid health plan (PHP) clients). Refer to OAR 410-147-0120 for more information regarding OHP encounters;

(b) Citizenship Waived Medical (CWM) clients. Refer also to OAR 410-120-1210(3)(f).

(d) Uninsured and/or self-pay clients;

(e) Medicare clients;

(f) Third party or private pay insurance clients;

(g) County- and/or clinic-pay clients (services paid or funded by the county or clinic); and

(h) Clients funded by federal, state, local or other grants.

(5) FQHCs and RHCs must exclude from the total number of reported encounters:

(a) Encounters attributed to non-allowable costs:

(A) Services performed under the auspices of a Women, Infant and Children (WIC) program or a WIC contract;

(B) Services performed and reimbursed under separate enrollment (e.g., Targeted Case Management);

(C) Services provided by patient advocates/ombudsmen and Outstationed Outreach Workers, employed by or under contract with the FQHC or RHC, for the primary purpose of providing outreach and/or group education sessions;

(D) Provider participation in a community meeting or group session that is not designed to provide clinical services. This includes, and is not limited to, information sessions for prospective Medicaid beneficiaries, and information presentations about available health services at the FQHC or RHC; and

(E) Health services provided as part of a large-scale "free to the public" or "nominal fee" effort, such as a mass immunization program, screening program, or community-wide service program (e.g., a health fair);

(b) Encounters for specific services outlined in 42 USC 1396d(a)(2)(B) and (C), that do not meet the criteria of a valid encounter when furnished as a stand-alone service. Costs for furnishing these services is an allowed administrative program cost and should be reported on a clinic's cost statement for calculating a clinic's PPS encounter rate. Refer to OAR 410-147-0480, Costs Statement (DMAP 3027) Instructions. Examples include, but are not limited to:

(A) Case management services for coordinating health care for a client;

(B) Enabling services, including but not limited to, sign language and oral interpreter services;

(C) Supportive, rehabilitation services including, but not limited to, environmental intervention, and supported housing and employment; skills training and activity therapy to promote community integration and job readiness;

(D) Laboratory and radiology services, including venipuncture and tuberculosis (TB) tests (the initial visit for the TB test administered to the epidermis);

(E) Prescription refills; and

(F) Services provided without the client present, except for telephone contacts as specified in this rule section (6)(c).

(6) FQHCs and RHCs are required to include encounters for services furnished by practitioners recognized by DMAP in OAR 410-147-0120(6). Examples of encounters that may be overlooked but should be included are:

(a) Encounters below the funding line on the Health Services Commission's Prioritized List of Health Services. All encounters are to be reported regardless of line placement;

(b) Encounters outside of the clinic by primary care practitioners (e.g. services furnished in a hospital or residential treatment setting);

(c) Telephone contacts as provided for in the Tobacco Cessation, OAR 410-130-0190; and Maternity Case Management (MCM), 410-130-0595, programs. See also 410-120-1200(2)(y);

(d) Medication management-only encounters by a behavioral health practitioner;

(e) Encounters by Registered and Licensed Practical Nurses:

(A) Home encounters in an area in which the Secretary of the Health Resources and Services Administration, Health and Human Services, has determined that there is a shortage of home health agencies (OAR 410-147-0120(10));

(B) Administration of immunizations/vaccinations encounters;

(D) Maternity Case Management (MCM) encounters.

(7) Global procedures require attention for accurate reporting of encounters:

(a) Obstetrics procedures: Each antepartum, delivery and postpartum encounter included in a global procedure for maternity and delivery services should be reported as a separate encounter;

(b) Dental procedures: Multiple contacts for global dental procedures should be reported as a single encounter. Refer to OAR 410-147-0040(5) ICD-10-CM Diagnosis and CPT/HCPCs Procedure Codes, for more information;

(c) Surgical procedures: Refer to OAR 410-147-0040(5), ICD-10-CM Diagnosis and CPT/HCPCs Procedure Codes, for more information:

(A) Services within a surgical package and "included" in a given CPT surgical code are reported as a single encounter. Refer to OAR 410-130-0380, Surgical Guidelines, for more information; and

(B) The initial consultation or evaluation of the problem by the provider to determine the need for surgery, and separate from a preoperative appointment, is a separate encounter.

(8) A surgical procedure furnished to an OHP client and provided by more than one surgeon employed by the FQHC or RHC does not count as multiple encounters. The exception to this rule is major surgery, including a cesarean delivery, furnished to a CWM client. Services provided by the primary surgeon and the assistant surgeon, when both are employed with the FQHC or RHC, may be eligible as multiple encounters if medically necessary.

(9) When two or more services are provided on the same date of service:

(a) With distinctly different diagnoses, a clinic should report multiple encounters when the criteria in OAR 410-147-0140, Multiple Encounters, is met; or

(b) With similar diagnoses, a clinic must report one encounter.

(10) Clinics must maintain, for no less than five years, all documentation relied upon by the clinic to calculate the number of encounters reported on the cost statement (DMAP 3027):

(a) All documentation supporting the number of encounters reported on the cost statement must be sufficient to withstand an audit; and

(b) The total number of encounters calculated from all sources of documentation must reconcile to the total number of encounters reported on the cost statement, and subtotaled encounters must reconcile to each documentation source relied upon.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 15-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 10-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0380
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
HR 7-1995, f. 3-31-95, cert. ef. 4-1-95
HR 13-1993, f. & cert. ef. 7-1-93
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91

Or. Admin. R. 410-147-0520 Depreciation

Office of Management and Budget (OMB) Circular A-87 and A-122, Section 13 is applicable with the following exception: depreciation and amortization must be calculated on a straight line basis less the estimated salvage value. The clinic must use the American Hospital Association guidelines “Estimated Useful Lives of Depreciable Hospital Assets” for determining asset lives when computing depreciation. For assets not covered by the guidelines and with costs of more than $500 individually and $500 aggregate, the lives established by the clinic are subject to approval by Division of Medical Assistance Programs (Division). Depreciation and amortization schedules must be maintained.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0260
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
HR 13-1993, f. & cert. ef. 7-1-93
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91

Or. Admin. R. 410-147-0540 Related Party Transactions

(1) A “related party” is an individual or organization that is associated or affiliated with, or has control of, or is controlled by the federally qualified health center (FQHC) or rural health clinic (RHC) furnishing the services, facilities, or supplies:

(a) “Common ownership” exists if an individual or individuals possess significant ownership or equity in the provider and the institution or organization serving the provider;

(b) “Control” exists if an individual or an organization has the power, directly or indirectly, significantly to influence or direct the actions or policies of an organization or institution.

(2) Division of Medical Assistance Programs (Division) allows costs applicable to services, facilities, and supplies furnished to the FQHC or RHC by a related party at the lower of cost, excluding profits and markups to the related party, or charge to the clinic. Such costs are allowable in accordance with 42 CFR 413.17, to the extent that they:

(a) Relate to Title XIX and Title XXI client care;

(b) Are reasonable, ordinary, and necessary; and

(3) The intent is to treat the costs incurred by the related party as if they were incurred by the FQHC/RHC itself.

(4) Clinics must disclose a related party who is separately enrolled as a provider with Division and furnish the provider’s National Provider Identifier (NPI) and associated taxonomy code(s).

(5) Documentation of costs to related parties shall be made available at the time of an audit or as requested by Division. If documentation is not available, such payments to or for the benefit of the related organization will be non-allowable costs.

(6) Division will allow rental expense paid to related individuals or organizations for facilities or equipment to the extent the rental does not exceed the related organization's cost of owning (e.g., depreciation, interest on a mortgage) or leasing the assets, computed in accordance with the provisions of the FQHC and RHC Administrative Rules.

(7) If all of these conditions are not met, none of the costs of the related party transaction can be reported as reimbursable costs on the FQHC or RHC’s cost statement report.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0280
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
HR 13-1993, f. & cert. ef. 7-1-93
HR 4-1991, f. 1-15-91, cert. ef. 2-1-91

Or. Admin. R. 410-147-0560 Sanctions

(1) Providers are directed to Division of Medical Assistance Programs' General Rules OARs 410-120-1400 Provider Sanctions and 410-120-1460 Type and Conditions of Sanctions and Oregon Health Authority OAR 943-120-0360 Consequences of Non-Compliance and Provider Sanctions.

(2) OAR 410-120-1510 and 943-120-0380 govern fraud and abuse. The Authority is authorized to take the actions necessary to investigate and respond to substantiated allegations of fraud and abuse, including but not limited to suspending or terminating the provider from participation in the medical assistance programs

History

Statutory/Other Authority: ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0395
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
HR 13-1993, f. & cert. ef. 71-1-93

Division 148 HOME ENTERAL/PARENTERAL NUTRITION AND INTRAVENOUS SERVICES (EPIV)

Or. Admin. R. 410-148-0000 Foreword

(1) The Home Enteral/Parenteral Nutrition and IV Services rules are a user's manual designed to assist providers in preparing health claims for medical assistance program clients. The Home Enteral/Parenteral Nutrition and IV Services provider rules are to be used in conjunction with the General Rules for Oregon Medical Assistance Programs, the Oregon Health Plan administrative rules, the Pharmaceutical Services administrative rules, the Early and Periodic Screening, Diagnostic and Treatment administrative rules, and other relevant provider rules and supplemental information.

(2) The Home Enteral/Parenteral Nutrition and IV Services provider rules include procedure codes with restrictions, and limitations. The Home EPIV code and fee schedule, which is not a part of these rules, is not an exhaustive list of OHP covered service codes. Please consult the Prioritized List of Health Services for the Oregon Health Plan and the Division’s Maximum Allowable Table.

(3) The Division endeavors to furnish medical providers with up-to-date billing, procedural information, and guidelines to keep pace with program changes and governmental requirements.

(4) Providers should always follow the Division administrative rules in effect on the date of service.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024
OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0600
HR 3-1995, f. & cert. ef. 2-1-95
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0020 Home Enteral/Parenteral Nutrition and IV Services

(1) The Division shall make payment for medically appropriate and medically necessary goods, supplies, and services for home enteral/parenteral nutrition and IV therapy on written order or prescription.

(a) The order or prescription must be dated and signed by a licensed prescribing practitioner. The order shall be legible and specify the service required, the ICD-10-CM diagnosis code(s), the route of administration, the amounts prescribed, and the length of time needed.

(b) The prescription or written practitioner’s order must be retained on file by the provider of service for the period of time specified in the Division's General Rules.

(c) A nutritional assessment performed by a registered dietitian or the treating practitioner and a new prescription are required once a year for ongoing services.

(d) Also covered are services for subcutaneous, epidural and intrathecal injections requiring pump or gravity delivery.

(2) All claims for enteral/parenteral nutrition and IV services require a valid ICD-10-CM diagnosis code. It is the provider's responsibility to obtain the actual diagnosis code(s) from the prescribing practitioner. Reimbursement shall be made according to covered services on funded lines of the Health Services Commission's Prioritized List of Health Services, and these rules.

(3) The Division shall cover one initial nursing service visit to assess the home environment and appropriateness of enteral/parenteral nutrition or IV services in the home setting when recommended by the treating practitioner to establish the client's treatment plan. This nursing service visit for assessment purposes does not require prior authorization.

(4) Nursing service visits, except the assessment nursing visit, specific to this Home Enteral/Parenteral and IV services program are provided in the home or an Ambulatory Infusion Suite of the Home Infusion Therapy Provider (AIS) and shall be reimbursed by the Division only when prior authorized, and performed by a person who is licensed by the Oregon State Board of Nursing to practice as a Registered Nurse. All registered nurse delegated or assigned nursing care tasks must comply with the Oregon State Board of Nursing, Nurse Practitioner Act and Administrative Rules regulating the practice of nursing.

(5) Payment for services identified in the Home Enteral/Parenteral Nutrition and IV Services provider rules shall be made only when provided in the client's place of residence.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0640
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 3-1995, f. & cert. ef. 2-1-95
HR 26-1993, f. & cert. ef. 10-1-93
HR 9-1992, f. & cert. ef. 4-1-92
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0290
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89

Or. Admin. R. 410-148-0040 Requirements for Home Enteral/Parenteral Nutrition and IV Services

(1) Home Enteral/Parenteral Nutrition and IV Services:

(a) Home enteral/parenteral nutrition and IV services must include training and/or education of client or support person on nutritional supplement and /or equipment operation;

(b) When enteral/parenteral nutrition and IV services are initiated in a hospital setting, reimbursement for training is included in the hospital reimbursement and will not be made separately;

(c) Reimbursement for enteral/parenteral and IV services training when done in the home is included in the payment for the nursing visit(s);

(d) Per diem reimbursement includes: administrative service, pharmacy professional and cognitive services, including drug admixture, patient assessment, clinical monitoring, and care coordination, and all necessary infusion related supplies and equipment. Enteral/parenteral formula, drugs and nursing visits are not included in per diem rates and must be billed separately.

(2) Home enteral nutrition:

(a) Home enteral nutrition is considered medically appropriate to maintain body mass and prevent nutritional depletion, which occurs with some illnesses or pathological conditions;

(b) Home enteral therapy may be administered orally or by enteral tube feeding, i.e., nasogastric, jejunostomy or gastrostomy delivery systems.

(3) Home parenteral nutrition:

(a) Is considered medically appropriate for treatment of gastrointestinal dysfunction such as severe short bowel syndrome, chronic radiation enteritis, severe Crohn’s disease, or other conditions where adequate nutrition by the oral and enteral routes is not possible:

(b) Initiation of home parenteral nutrition services must include client or support person education on catheter care, infusion technique, solution preparation, sterilization technique, and equipment operation;

(4) Home intravenous (IV) services:

(a) Home intravenous (IV) services are covered by the Division for the administration of antibiotics, analgesics, chemotherapy, hydrational fluids or other intravenous medications in a client’s residence, (i.e., home or nursing facility) or an Ambulatory Infusion Suite (AIS).

(b) In addition, the provision of all goods and services needed for maintaining venous or arterial access and required monitoring is covered.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0660
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
HR 3-1995, f. & cert. ef. 2-1-95
HR 11-1994, f. 2-25-94, cert. ef. 2-27-94
HR 34-1993(Temp), f. & cert. ef. 12-1-93
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 9-1992, f. & cert. ef. 4-1-92
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0060 Authorization

(1) The Division requires authorization of payment for the following items or services:

(a) All nursing service visits, except the assessment nursing visit, associated with home enteral/parenteral nutrition or IV services;

(b) All oral formula and nutritional supplements;

(d) Items and services identified as requiring authorization in OAR Chapter 410, Division 148 administrative rules;

(e) All drugs and goods identified as requiring payment authorization in the Pharmaceutical Services administrative rules (chapter 410, division 121). Contact the Division’s Pharmacy Benefit Manager to determine those items that require prior authorization.

(2) The Division shall approve payment for the above home enteral/parenteral nutrition and/or IV services entities when the Division administrative rules are met, and services are medically appropriate and medically necessary as defined in OAR Chapter 410 Division 120 for adult beneficiaries and as defined in Chapter 410 Division 151 for EPSDT beneficiaries.

(3) The Division requires authorization of payment for those services that require authorization even though the client has other insurance that may cover the service. Authorization of payment is not required for Medicare covered services.

(4) For services requiring authorization, providers must contact the Division’s Medical Unit for authorization within five (5) working days following initiation of services. Authorization shall be given based on medical appropriateness, appropriateness of level of care given, cost and/or effectiveness.

(5) How to obtain payment authorization:

(a) The Division’s Medical Unit is responsible for authorization for services for clients identified as Medically Fragile Children's Unit clients;

(b) Contact the Division’s Pharmacy Benefit Manager, prior authorization help desk to request oral nutrition supplements;

(d) Payment authorization does not guarantee reimbursement.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024
DMAP 38-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 26-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0680
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 3-1995, f. & cert. ef. 2-1-95
HR 26-1993, f. & cert. ef. 10-1-93
HR 9-1992, f. & cert. ef. 4-1-92
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0220
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0090
AFS 4-1989, f. 1-31-89, cert. ef. 2-1-89
AFS 15-1987, f. 3-31-87, cert. ef. 4-1-87
AFS 52-1986, f. & cert. ef. 7-2-86
AFS 53-1985, f. 9-20-85, cert. ef. 10-1-85
AFS 26-1984, f. & cert. ef. 6-19-84
AFS 12-1984, f. 3-16-84, cert. ef. 4-1-84
AFS 99-1982, f. 10-25-82, cert. ef. 11-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 44-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 70-1981, f. 9-30-81, cert. ef. 10-1-81
PWC 869, f. 12-30-77, cert. ef. 1-1-78
PWC 831, f. 2-18-77, cert. ef. 3-1-77
PWC 818(Temp), f. 10-22-76, cert. ef. 11-1-76

Or. Admin. R. 410-148-0080 Equipment Rental/Purchase/Repair

(1) The following equipment shall be covered, if medically appropriate and when cost effective, on a rental basis only:

(a) IV/Parenteral nutrition infusion pumps;

(b) Enteral nutrition infusion pumps;

(2) The equipment provider is responsible for providing working rental equipment including replacement if repairs are necessary.

(3) Rental payment for the enteral nutrition infusion pumps and the parenteral nutrition infusion pumps shall not be made beyond the purchase price or beyond fifteen (15) consecutive months (whichever is least costly).;

(a) Consecutive months are defined as "any period of continuous use where no more than a 60-day break occurs".

(b) Having met the purchase price, as described in this rule, the pump becomes the property of the client;

(A) The Division may allow for medically necessary repairs on equipment the patient owns when the repairs are not covered under any manufacturer/supplier warranty.

(B) The provider may bill the Division for maintenance and servicing of the pump (as long as the maintenance and servicing is not covered under any manufacturer/supplier warranty) when a period of at least six (6) months has elapsed since the final month of pump rental.

(C) Payment for the maintenance and servicing shall only be made one (1) time during every six (6) month period and only for actual incidents of maintenance and servicing.

(D) For a purchased pump, a rental pump may be covered for up to one (1) month during equipment repair for a client requiring medically necessary, continuous service. Use HCPCS code K0462 when billing for the temporary rental pump while the patient-owned pump is being repaired;

(4) Reasonable useful lifetime of an enteral nutrition infusion pump and parenteral nutrition infusion pump is no less than eight (8) years. Computation of the useful lifetime is based on the date the pump was dispensed to the client, not the age of the pump.

(5) All other equipment for home enteral/parenteral nutrition and IV services shall be covered as either purchase or based on length of need and medical appropriateness.

(6) All rental or purchase of equipment, full services warranty, pickup, delivery, set-up, fitting, and adjustments are included in the reimbursement. Individual consideration may be given in specific circumstances upon written request to the Division.

(7) Repair of rental equipment is the responsibility of the provider.

(8) The Division shall not make payment for rental of pumps that are supplied by any manufacturer at no cost to the provider.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024
OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0700
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 3-1995, f. & cert. ef. 2-1-95
HR 20-1991, f. & cert. ef. 4-16-91
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0100 Reimbursement

(1) Drug ingredients (medications) shall be reimbursed as defined in the Division of Pharmaceutical Services administrative rules (chapter 410, division 121).

(2) The following service/goods shall be reimbursed on a fee-for-service basis according to the Division EPIV Fee Schedule found in the Home Enteral/Parenteral Nutrition and IV Services on the Division website:

(a) Enteral formula which is medically appropriate and meets the criteria specified in Chapter 410, Division 148 administrative rules;

(b) Oral nutritional supplements which are medically appropriate and meet the criteria specified in Chapter 410, Division 148 administrative rules;

(c) Parenteral nutrition solutions which are medically appropriate and meet the criteria specified in Chapter 410, Division 148 administrative rules;

(3) Reimbursement for services shall be based on the lesser of the amount billed, or the Division maximum allowable rate. When the service is covered by Medicare, reimbursement shall be based on the lesser of the amount billed, Medicare’s allowed amount, or the Division maximum allowable rate.

(4) Reimbursement for supplies that require authorization or services/supplies that are listed as Not Otherwise Classified (NOC) or By Report (BR) must be billed to the Division at the providers' acquisition cost and shall be reimbursed at such rate.

(a) For purposes of this rule, Acquisition Cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer (or supplier) plus any shipping and/or postage for the item. Submit documentation identifying acquisition cost with your authorization request;

(b) Per diem, as it relates to reimbursement, represents each day that a given patient is provided access to a prescribed therapy. This definition is valid for per diem therapies of up to and including every 72 hours.

(A) Professional pharmacy services:

(i) Initial and ongoing assessment/clinical monitoring;

(ii) Coordination with medical professionals, family and other caregivers;

(iii) Sterile procedures, including IV admixtures, clean room upkeep and all biomedical procedures necessary for a safe environment;

(iv) Compounding of medication/medication set-up.

(B) Infusion therapy related supplies:

(i) Durable, reusable or elastomeric disposable infusion pumps;

(ii) All infusion or other administration devices;

(iii) Short peripheral vascular access devices;

(iv) Needles, gauze, sterile tubing, catheters, dressing kits, and other supplies necessary for the safe and effective administration of infusion therapy.

(5) Reimbursement shall not be made for the following:

(a) Central catheter insertion or transfusion of blood/blood products in the client's home;

(b) Central catheter insertion in the nursing facility;

(d) Oral nutritional supplements when the client is able to meet recommended caloric/protein and micronutrient intake through the consumption of food items or meals;

(e) Tocolytic pumps for pre-term labor management;

(f) Home enteral/parenteral nutrition or IV services outside of the client's place of residence. A client’s place of residence can be an assisted living facility, 24-hour residential care facility, adult foster home, child foster home, or a private home.

(6) The Oregon Health Plan (OHP) shall be primary payer, before the Women’s, Infant and Children (WIC) program, for all formula covered by OHP to treat those infants and children who are enrolled in both OHP and participating in the WIC program.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024
DMAP 95-2024, amend filed 05/30/2024, effective 07/01/2024
DMAP 33-2024, temporary amend filed 01/12/2024, effective 01/12/2024 through 07/09/2024
DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0720
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0120 Reimbursement Limitations for Clients in a Nursing Facility

(1) The Division of Medical Assistance Programs (Division) will not reimburse for the following services/supplies for clients residing in a nursing facility:

(a) Nursing service visits (including assessment visit). Refer to Aging and People with Disabilities (APD) administrative rule covering all-inclusive rate;

(b) Supplies and items covered in the nursing facility All-inclusive rate. Refer to the Supplemental Information section of the Home Enteral/Parenteral Nutrition and IV Services provider website (http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Home-EPIV.aspx) for a listing of those supplies and items;

(2) The Division will reimburse for the following:

(a) Oral nutritional supplements are covered by the Division for nursing facility clients when medically appropriate, i.e., the client cannot consume food items or meals;

(b) Tube fed enteral nutrition formula, when medically appropriate;

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 64-2018, minor correction filed 05/25/2018, effective 05/25/2018
OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0730
HR 11-1994, f. 2-25-94, cert. ef. 2-27-94
HR 34-1993(Temp), f. & cert. ef. 12-1-93
HR 26-1993, f. & cert. ef. 10-1-93

Or. Admin. R. 410-148-0140 Billing Information

(1) For medications:

(a) Pharmacies billing electronically bill through the Division of Medical Assistance Program (Division) pharmacy benefit manager, point of sale. For more information on point of sale, contact the Division’s pharmacy benefit manager’s help desk;

(b) Only those pharmacies and Home Enteral/Parenteral Nutrition and IV (EPIV) providers billing manually for medications and home IV drug ingredients that are not billed through point of sale may use the CMS 1500 claim form or the 837P electronic claim form (instructions in home enteral/parenteral and IV services supplemental guide;

(2) For home enteral/parenteral and IV services other than medications:

(a) Providers must use the CMS 1500 form to bill for home enteral/parenteral nutrition and IV services identified with a five-digit Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT). Use the billing instructions found in the Home Enteral/Parenteral Nutrition and IV Services supplemental materials;

(b) See OAR 410-148-0160 for billing clients with Medicare coverage.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 26-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0740
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 9-1992, f. & cert. ef. 4-1-92
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0160 Billing for Clients Who Have Both Medicare and Basic Health Care Coverage

(1) The Division of Medical Assistance Programs (Division) may be billed directly for services provided to a client when the provider has established and clearly documented in the client's record that the service provided does not qualify for Medicare reimbursement.

(2) When the service qualifies for Medicare reimbursement, bill as follows:

(a) When billing for home enteral/parenteral nutrition services:

(A) Bill in the usual manner to the local or designated Medicare Intermediary;

(B) After Medicare makes a payment determination, bill the Division on the DMAP 505 form following the billing instructions and using the procedure codes listed for the Home Enteral/Parenteral Nutrition and IV Services in the fee schedule and supplemental materials;

(b) When billing for Home EPIV services:

(A) Bill the local Medicare Intermediary in the usual manner;

(B) After Medicare makes payment determination, bill the Division following the billing instructions and using the procedure codes listed for the Home EPIV Services fee schedule and supplemental materials.

[Publications: Publications referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0750
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 3-1995, f. & cert. ef. 2-1-95
HR 26-1993, f. & cert. ef. 10-1-93
HR 9-1992, f. & cert. ef. 4-1-92

Or. Admin. R. 410-148-0260 Home Enteral Nutrition

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover home enteral formula, oral nutritional supplements, equipment, supplies, and services for clients of any age. Refer to Table 148-0260-1 and the following guidelines:

(a) Enteral nutrition refers to nutritional formula administered by tube or orally fed into the gastrointestinal tract (HCPCS codes may include, but are not limited to, B4149 through B4162). Depending on the route of administration, additional equipment and supplies may be covered;

(b) Blenderized enteral formula, whether administered by tube or orally fed, describes formulas containing natural foods that are blenderized and packaged by a manufacturer. Code B4149 must not be used for foods that have been blenderized by the beneficiary or caregiver;

(c) Refer to the product classification list on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor website for appropriate Healthcare Common Procedure Coding System (HCPCS) codes assigned to formula, supplements, equipment, and supplies;

(d) If the formula, item, or supply is not listed on the PDAC contractor website, the provider must contact the PDAC contractor for a coding determination. The Medicare Pricing, Data Analysis and Coding contractor is responsible for assisting DMEPOS providers and manufacturers in determining which HCPCS code shall be used to describe DMEPOS items;

(2) Enteral formula and nutritional supplements administered orally;

(a) Prior authorization is required.

(b) Enteral formula and oral nutritional supplements documented as the primary source of nutrition, for a client of any age, meets criteria for expedited prior authorization review;

(A) For Adults:

(i) An assessment performed by a registered dietitian or treating practitioner, at onset and annually thereafter, documenting the client is unable to meet their recommended caloric/protein or micronutrient needs through regular, liquified, blenderized, or pureed foods in any modified texture or form; and

(ii) Documentation showing the prescribed oral nutritional formula and/or nutritional supplements are an integral part of treatment for a nutritional deficiency as identified by one of the following conditions:

(I) Diagnosed acute or chronic malnutrition; or

(II) Documentation of weight, either currently or historically, supported by oral nutritional supplements; or

(III) Increased metabolic need resulting from severe trauma; or

(IV) Malabsorption difficulties (e.g., short-gut syndrome, fistula, cystic fibrosis, renal dialysis); or

(V) Inborn errors of metabolism (e.g., fructose intolerance, galactosemia, maple syrup urine disease (MSUD), or phenylketonuria (PKU); or

(VI) Ongoing cancer treatment, advanced Acquired Immune Deficiency Syndrome (AIDS) or pulmonary insufficiency; or

(VII) Oral aversion or other psychological condition making it difficult for a client to consume their recommended caloric/protein or micronutrient needs through regular, liquified, blenderized, or pureed foods in any modified texture or form;

(B) For EPSDT Beneficiaries as defined in Chapter 410 Division 151:

(i) An assessment performed by a registered dietitian or treating practitioner, at onset and annually thereafter, documenting the prescribed nutritional formula and/or nutritional supplementation is medically necessary and appropriate as an integral part of treatment for any condition noted above (I-VII) or for the prevention of nutritional deficiency or malnutrition as identified by one of the following:

(I) Documentation showing the client is unable to meet their recommended caloric/protein or micronutrient needs through regular, liquified, blenderized, or pureed foods in any modified texture or form; or

(II) Malabsorption or other diagnosed medical condition which involves dietary restriction as part of the treatment, including but not limited to food allergy, Eosinophilic disorders (EoE), Food Protein Induced Enterocolitis (FPIES); or

(III) Documented delayed growth or failure to thrive;

(ii) For EPSDT beneficiaries, the terms medically necessary and medically appropriate are defined in OAR Chapter 410 Division 151;

(3) Enteral formula administered by tube for a client of any age:

(a) Enteral nutrition is covered for a client of any age who requires feedings via an enteral access device (tube) to provide sufficient nutrients to maintain weight and strength otherwise not possible by dietary adjustment and/or oral supplements;

(b) Supplies:

(A) The unit of service for the supply allowance (B4034, B4035, B4036, or B4148) is one (1) per day;

(i) Enteral feeding supply kit allowances (B4034, B4035, B4036, and B4148) are all-inclusive with the exception of B4105 in-line digestive enzyme cartridge.

(ii) Two in-line digestive enzyme cartridges (B4105) per day is considered reasonable and necessary for clients diagnosed with Exocrine Pancreatic Insufficiency (EPI);

(iii) The feeding supply allowance (B4034, B4035, B4036, and B4148) must correspond with the method of administration (syringe, pump, gravity, elastomeric control fed);

(I) The daily supply allowances include, but are not limited to, a catheter/tube anchoring device, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device;

(II) Prior authorization is required for specialty supply items (e.g., Farrell Valve) and there must be documentation to support the need;

(B) Three nasogastric tubes (B4081, B4082, and B4083), or one gastrostomy/jejunostomy tube (B4087 or B4088) every three (3) months is considered reasonable and necessary. One back-up gastrostomy/jejunostomy tube (B4087 or B4088) may be covered when prescribed for an EPSDT beneficiary as defined in Chapter 410 Division 151. For those clients requiring more frequent changes or replacement of a non-functional tube, prior authorization is required and there must be documentation to support the need;

(4) Initial delivery of each enteral formula, oral supplement, equipment, and supplies:

(a) For each new formula or supplement prescribed, suppliers shall provide a sixty (60) day supply regardless of which delivery method is utilized.

(b) The prescribed length of need must exceed sixty (60) days for this rule to apply;

(5) Refill requirements for formula items and supplies provided on a recurring basis:

(a) For all formulas, nutritional supplements, and supplies that are provided on a recurring basis as refills to the original order, suppliers are required to have contact with the client or designee either by call, text, or email prior to dispensing to confirm any changes or modifications to the order;

(b) Contact with the client or designee regarding refills shall take place no less than 35 calendar days prior to the end of usage for the current product and the next scheduled delivery/shipping date;

(c) For delivery or shipment of refills, the supplier shall dispense the formula and supplies no less than thirty (30) calendar days prior to the end of usage for the current product regardless of which delivery method is utilitzed;

(A) Regardless of utilization, a supplier must not dispense more than a 1-month quantity of formula or supplies on a recurring basis;

(B) Automatic shipments on a pre-determined basis, even if authorized by the client or designee, are not allowed;

(C) Suppliers may dispense more than a 1-month quantity of formula or supplies only on a periodic basis to ensure continuation of care during times of travel or when the client is away from the home for an extended period of days. Documentation of the reason for the additional quantity and client’s travel or time away from home, shall be kept on file with the supplier and made available to the Division upon request.

(6) For enteral nutrition equipment, all repair and maintenance are subject to rule OAR 410-148-0080;

(7) Food thickener (B4100) administered orally:

(a) A thickener is an additive that decreases the flow rate of thin liquids. A thickener, when medically necessary and medically appropriate, shall be covered when prescribed for a client of any age who has participated in a swallowing evaluation or study and for the treatment of a swallowing disorder resulting from one of the following:

(A) A diagnosis of dysphagia which negatively impacts the ability to swallow; or

(B) Chronic diseases such as, but not limited to, Parkinson’s, dementia, reflux disease, stroke, neuromuscular disease/disorder, and spinal cord injury; or

(D) Documented aspiration of food or liquid associated with chronic illness or disease.

(b) Annual follow up with treating practitioner is required to ensure the food thickener remains medically necessary and to confirm any changes or modifications to the order.

(8) Oral nutritional formula and supplements may be covered through the point-of-sale pharmacy system. Refer to the Pharmaceutical Services administrative rules, Chapter 410 Division 121, for coverage and prior authorization requirements;

(9) Human donor milk:

(a) Refer to the Prioritized List Guideline Note for coverage guidelines;

(b) Prior authorization is required;

(10) Procedure codes:

(a) Refer to Table 148-0260-1;

(b) Codes that have “PA” indicated require prior authorization;

(11) Billing instructions:

(a) The allowance for all items includes delivery regardless of which delivery method is utilized;

(b) Oral formula and/or nutritional supplements can be billed through the on-line point of sale pharmacy system, or by paper using the CMS 1500 claim form or the electronic 837P claim form. Providers are required to use the product’s National Drug Code (NDC) and Healthcare Common Procedure Coding System (HCPCS) code when billing the CMS 1500 or electronic 837P claim form;

(12) Documentation requirements:

(a) The purchase, rental, or repair of durable medical equipment and the purchase of supplies must have an order from the prescribing practitioner prior to dispensing items to a client;

(b) A new prescription is required when:

(A) There is a change in the item(s), frequency of use, amount prescribed, a change in the length of need, or a previously established length of need expires.

(B) A new prescription is required annually;

(c) For services requiring prior authorization (PA), submit documentation that supports coverage criteria in this rule are met;

(d) All nutritional formula, equipment, supplies, and services shall be documented as medically appropriate and medically necessary by the registered dietitian and/or treating practitioner;

(A) “Medically Appropriate” has the meaning given that term in OAR Chapter 410 Division 120 for adult beneficiaries, and as defined in Chapter 410 Division 151 for EPSDT beneficiaries;

(B) “Medically Necessary” has the meaning given that term in OAR Chapter 410 Division 120 for adult beneficiaries, and as defined in Chapter 410 Division 151 for EPSDT beneficiaries;

(e) Documentation that coverage criteria have been met must be present in the client’s medical records. These records shall be kept on file with the DME provider and made available to the Division on request.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024
DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 52-2006, f. 12-28-06 cert. ef. 1-1-07
OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0840
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 3-1995, f. & cert. ef. 2-1-95
HR 26-1993, f. & cert. ef. 10-1-93
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0280 Home Parenteral Nutrition

(1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report.

(2) Standard Total Parenteral Nutrition (TPN):

(a) Bill using Healthcare Common Procedure Coding System (HCPCS) codes S9365 through S9368;

(b) Home infusion for stand TPN includes the following drugs and products in the per diem rate:

(A) Non-specialty amino acids (e.g., aminosyn, freeamine, travasol)

(B) Concentrated dextrose (e.g., D10, D20, D40, D50, D60, D70)

(D) Electrolytes (e.g., CaC12, KCL, KPO4, MgSo4, NaAc, NaCl, NaPO4);

(E) Standard multi-trace elements (e.g., MTE4, MTE5, MTE7);

(F) Standard multi-vitamin solutions (e.g., MVI-13).

(A) Specialty amino acids for renal failure, hepatic failure or for high stress conditions (e.g., aminess, aminosyn-RF, nephramine, RenAmin, HepatAmine, Aminosyn-HBC, BranchAmin, FreeAmine HBC, Trophamine);

(B) Specialty amino acids with concentrations of 15% and above when medically necessary for fluid restricted patients (e.g., Aminosyn 15%, Novamine 15%, Clinisol 15%);

(D) Added trace elements, vitamins not from standard multitrace element or multivitamin solution;

(E) Products serving non-nutritional purposes (e.g., heparin, insulin, iron dextran).

(2) Parenteral Nutrition Solutions:

(a) Bill using HCPCS codes B4164 through B5200. See HCPCS book for description.

(b) Note: Reimbursement for compounding, admixture and administrative fees is included in the unit price.

(3) Parenteral Supply Kits/Supplies — Procedure Codes

(4) Parenteral Nutrition Equipment — Procedure Codes — Table 0280-1.

(5) Not Otherwise Classified (NOC) — B9999, NOC For Parenteral Supplies — PA/BR.

[ED. NOTE: Tables referenced are available from the agency.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0860
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 3-1995, f. & cert. ef. 2-1-95
HR 26-1993, f. & cert. ef. 10-1-93
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0300 Other Home IV and Enteral/Parenteral Administration Services

(1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report.

(2) Catheter Care Kits. All catheter care kit allowable amounts are determined on a per diem basis (1 day = 1 unit):

(a) When performed as a stand alone therapy, or during days not covered under per diem by another therapy, bill using catheter care codes S5497 through S5521;

(b) The following supplies for non-routine catheter procedures may be billed separately from per diem reimbursement:

(A) S5517 Catheter declotting supply kit, 1 day = 1 unit;

(B) S5518 Catheter repair supply kit, 1 day = 1 unit;

(D) S5521 Midline insertion supply kit, 1 day = 1 unit.

(E) E0776 IV Pole — Purchase.

(F) E0776 with modifier RR IV Pole — Rental, 1 day = 1 unit

(3) Home Nursing Visits:

(a) When enteral/parenteral services are performed in the home, only a single provider of skilled home health nursing services may obtain authorization and/or bill for such services for the same dates of service;

(b) Requests made by providers for any intravenous or enteral/parenteral related skilled nursing services, either solely or in combination with any other skilled nursing services in the home are to be reviewed for prior authorization by the Division of Medical Assistance Programs (Division) Medical Unit;

(A) 99601, Home infusion/specialty drug administration, per visit (up to 2 hours). Modifier SS is used to indicate — Home infusion services provided in the infusion suite of the IV therapy provider — 1 visit = 1 unit — PA;

(B) 99602, each additional hour. List separately in addition to code for primary procedure). Modifier SS is used to indicate — Home infusion services provided in the infusion suite of the IV therapy provider. Use 99602 in conjunction with 99601 — PA;

(4) Not Otherwise Classified (NOC) — S9379, NOC for Home IV Supplies — PA/BR.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07
OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0880
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 26-1993, f. & cert. ef. 10-1-93
HR 46-1990, f. & cert. ef. 12-28-90
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Or. Admin. R. 410-148-0320 Billing Quantities, Metric Quantities and Package Sizes

(1) Use the following metric conversions when billing;

(a) Fluid Ounce — 30 ml;

(b) Pint — 480 ml;

(d) Gallon — 3,840 ml;

(e) Ounce (solids) — 30 gm;

(f) Pound (solids) — 454 gm.

(2) Use the following units when billing products:

(a) Solid substances (e.g., powders, creams, ointments, etc.), bill per gram;

(b) Solid substances that are reconstituted with a liquid (e.g., dry powder ampules and vials) such as antibiotic vials or piggybacks must be billed in metric quantity of one each;

(c) Tablets, capsules, suppositories, lozenges, packets bill per each unit. Oral contraceptives are to be billed per each table;

(d) Diagnostic supplies (e.g., chemstrips, clinitest tabs), bill per each unit;

(e) Injectables that are prepackaged syringe (e.g., tubex, carpujects), bill per ml;

(f) Medical Supplies (e.g., Testape, Cordran tape) bill in metric quantity of one each;

(g) Prepackaged medications and unit doses must be billed per unit (tablet or capsule). Unit dose liquids are to be billed by ml;

(h) Fractional ml liquid doses (e.g., flu vaccine, pneumovax, etc.) use unique codes and bill per each dose;

(i) Fractional units: If no unique codes are available, round quantity up to the next whole unit (e.g., 3.5 gm to 4.0 gm; 7.2 ml up to 8 ml).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0900
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90

Division 150 ADMINISTRATIVE EXAMINATION AND BILLING SERVICES

Or. Admin. R. 410-150-0005 Purpose

The Administrative Examination and Report rules are provided for use in conjunction with the General Rules of the Division of Medical Assistance Programs (DMAP) to assist providers in completing examinations requested and in preparing claims for administrative evaluations and reports. Division 150 rules do not apply to managed care plans.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 41-2019, adopt filed 10/01/2019, effective 12/01/2019

Or. Admin. R. 410-150-0010 Definitions

(1) Administrative Examination – A medical or psychological evaluation required by the Department of Human Services (DHS), Oregon Health Authority (OHA), or Oregon Youth Authority (OYA) to assist in determining eligibility and for casework planning for various programs. An evaluation must be written and must contain a diagnosis, prognosis, and supporting objective findings. Functional impairments and expected duration of impairment must be included.

(2) Administrative Medical Reports -- Copies of existing records from a specified date. Progress notes, laboratory tests, x-ray reports, special test results and copies of other pertinent records must be included.

(3) Good Cause – Circumstances beyond a person’s control, or if a serious illness or death, medical, mental or emotional, learning or language impairment impeded ability to comply with necessary actions timely.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 41-2019, adopt filed 10/01/2019, effective 12/01/2019

Or. Admin. R. 410-150-0040 Request Requirements

(1) A completed OHP 729 Administrative Medical Examination/Report Authorization is the prior authorization needed to perform an administrative examination, complete supplemental forms, or send copies of records.

(a) Only the version of the OHP 729 series that is current as of the date of request is valid. The current OHP 729 series is available online at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin-Exam.aspx.

(b) Only an employee of the Department of Human Services (DHS) or Oregon Youth Authority (OYA), or the Division (OHA) may complete the OHP 729.

(2) There are a series of OHP 729 forms that may or may not be necessary to complete. Always follow the instructions on the OHP 729.

(3) Examinations are only to be completed by the provider type listed on the Administrative Exam and Report Codes table found at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin-Exam.aspx.

(4) An administrative medical examination or report requested must be in compliance with the policies outlined in the Division worker guide found at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin Exam.aspx.

(5) Claims may only be submitted by a Division-enrolled provider who:

(a) Is contracted with DHS, OYA or the Division to provide Administrative Medical Examinations and Reports;

(b) Meets acceptable source criteria for the agency making the request; and

(6) Providers may only perform the services included on the OHP 729 as requested by a DHS, OYA or Division employee. Providers must:

(a) Provide the requested report within 15 days, as noted on the OHP 729, unless there is good cause for a delay.

(b) Follow the instructions for all forms received in the OHP 729 series, and

(7) Individuals needing an Administrative Exam who do not have other means of transportation, may use Non-Emergent Medical Transportation (NEMT). Authorizing staff must follow the NEMT Worker Guide, policies and associated rules in Oregon Administrative Rules 410-136.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 15-2020, temporary amend filed 03/26/2020, effective 03/26/2020 through 09/21/2020
DMAP 41-2019, amend filed 10/01/2019, effective 12/01/2019
DMAP 65-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 46-2012, f. 10-11-12, cert. ef. 10-15-12
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 27-2000, f. 9-28-00, cert. ef. 10-1-00

Or. Admin. R. 410-150-0070 Billing Instructions for Administrative Examinations

(1) When an examination is needed, administrative examination codes are authorized by the branch office.

(2) Medical and ancillary services providers must bill using the Provider Web Portal at https://www.or-medicaid.gov or on a CMS-1500, mailed to the address listed on the OHP 729 at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin-Exam.aspx.

(3) Hospital services must be billed on a UB-04.

(4) Record copying fees imposed by a copy service provider must be billed on a CMS – 1500.

(5) For Administrative Examination billing, the following are required on the appropriate billing form:

(a) The procedure codes specified on the OHP 729;

(b) The diagnosis code Z02.89.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 41-2019, adopt filed 10/01/2019, effective 12/01/2019

Or. Admin. R. 410-150-0090 Billing Instructions - Licensed Polygraphist

(1) Billing for licensed polygrapher services must be submitted using the Provider Web Portal at https://www.or-medicaid.gov or on a CMS-1500, mailed to the address listed on the OHP 729.

(2) A polygraph does not qualify as a health care service, therefore it is not subject to Health Insurance Portability and Accountability Act (HIPAA) regulations.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
DMAP 41-2019, adopt filed 10/01/2019, effective 12/01/2019

Division 151 Early and Periodic Screening, Diagnostic and Treatment

Or. Admin. R. 410-151-0000 Early and Periodic Screening, Diagnostic and Treatment Program

(1) The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program offers comprehensive and preventive health care services to EPSDT Beneficiaries in accordance with 42 CFR § 441 Subpart B. EPSDT provides EPSDT Medically Necessary and EPSDT Medically Appropriate Medicaid-covered services to treat any physical, dental, vision, developmental, nutritional, and mental and behavioral health conditions. Coverage for EPSDT Beneficiaries includes all services coverable under the Oregon Health Plan (OHP), when EPSDT Medically Necessary and EPSDT Medically Appropriate for the EPSDT Beneficiary.

(2) The EPSDT rules in this division relating specifically to the provision of OHP services for EPSDT Beneficiaries take precedence over any and all general rules relating to the provision of OHP services to the general OHP population set forth in Oregon Administrative Rules Chapters 410 and 309.

(3) Physicians or other practitioners of the healing arts as defined in OAR 410-120-0000 within the scope of their practice under State law may provide OHP services to EPSDT Beneficiaries.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0001 Definitions.

The definitions in this rule apply to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program only.

(1) “EPSDT Dentally Appropriate”

(a) Means dental services, items, or dental supplies that are:

(A) Recommended by a licensed health practitioner practicing within the scope of their license; and

(B) Safe, effective, and appropriate for an EPSDT Beneficiary based on standards of good dental practice and generally recognized by the relevant scientific or professional community based on the best available evidence, which includes medical literature and expert consensus opinion and takes into account EPSDT Beneficiary values; and

(C) Impactful in improving access to care, ability to actively participate in care, work, school, or social activities; and not solely for the convenience or preference of an EPSDT Beneficiary, caregiver, or a provider of the service, item, or dental supply; and

(D) The most cost-effective level or type of health services, items, or supplies that are covered services that can be safely and effectively provided to an EPSDT Beneficiary.

(b) All covered services must be EPSDT Dentally Appropriate for the EPSDT Beneficiary but not all EPSDT Dentally Appropriate services are covered services.

(2) “EPSDT Beneficiary” means an individual under the age of 21 who is covered by the Oregon Health Plan (OHP) or an individual in the Young Adults with Special Health Care Needs (YSHCN) program as defined in OAR 410-200-0455

(3) “EPSDT Medically Appropriate:”

(a) Means health services, items, or medical supplies that are:

(A) Recommended by a licensed health practitioner practicing within the scope of their license; and

(B) Safe, effective, and appropriate for the EPSDT Beneficiary and generally recognized by the relevant scientific or professional community based on the best available evidence, which includes medical literature and expert consensus opinion and takes into account EPSDT Beneficiary values; and

(C) Impactful in improving access to care, ability to actively participate in care, work, school, or social activities and not solely for the convenience or preference of an EPSDT Beneficiary, caregiver, or a provider of the service, item, or medical supply; and

(D) The most cost-effective level or type of health services, items, or medical supplies that are covered services that can be safely and effectively provided to an EPSDT Beneficiary.

(b) All covered services must be EPSDT Medically Appropriate for the EPSDT Beneficiary, but not all EPSDT Medically Appropriate services are covered services.

(4) “EPSDT Medically Necessary:”

(a) Means health services, items and medical supplies that are required to address one or more of the following for an EPSDT Beneficiary:

(A) The prevention, diagnosis, treatment or amelioration of an EPSDT Beneficiary’s disease, condition, or disorder that results in health impairments or a disability;

(B) The ability for an EPSDT Beneficiary to achieve age-appropriate growth and development. Services that may be EPSDT Medically Necessary to achieve age-appropriate growth and development include but may not be limited to services that are reasonably calculated to improve the EPSDT Beneficiary’s ability to participate in work or school, or the prevention, diagnosis, detection, treatment, cure, correction, reduction, or alleviation of the effects of a physical, mental, behavioral, nutritional, dental, genetic, developmental or congenital condition, injury, or disability, regardless of whether they are consistent with the condition and treatment pairs identified in Prioritized List of Health Services (defined in OAR 410-120-0000) or are below the funding line on the Prioritized List of Health Services;

(C) The ability for an EPSDT Beneficiary to attain, maintain, or regain independence in self-care, ability to perform activities of daily living or improve health status; or

(D) The opportunity for an EPSDT Beneficiary receiving Long Term Services & Supports (LTSS) to have access to the benefits of non-institutionalized community living, to achieve person-centered care goals, to participate in their own care planning, and to live and work in the setting of their choice.

(b) An EPSDT Medically Necessary service must also be EPSDT Medically Appropriate. All covered services must be EPSDT Medically Necessary for the EPSDT Beneficiary.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0002 Coverage Requirements

(1) The coverage requirements for services to EPSDT Beneficiaries set forth in this Rule supersede any other coverage standards or requirements set forth in any other Medical Assistance rules that are applicable to non-EPSDT Beneficiaries, regardless of whether the other standards or requirements conflict or are otherwise inconsistent with the EPSDT coverage requirements in this Rule.

(2) The Oregon Health Authority (the Authority) and Managed Care Entities (MCEs) must cover services that are EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) for EPSDT Beneficiaries, even if:

(a) The services are not included or paired on the Prioritized List of Health Services (defined in OAR 410-120-0000); or

(b) The service is below the funding line on the Prioritized List of Health Services.

(3) The Authority and MCEs may not deny coverage of services for EPSDT Beneficiaries without a case-by-case review for EPSDT Medical Necessity and EPSDT Medical Appropriateness (or EPSDT Dental Appropriateness). It is allowable for services to be denied for EPSDT Beneficiaries after a case-by-case review in which it is determined by the Authority or the MCE that the service is not EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) for that specific EPSDT Beneficiary. Specific circumstances in which the Authority and MCEs may deny coverage of services for an EPSDT Beneficiary are outlined in a guidance document, effective January 1, 2023, available at https://www.oregon.gov/oha/hsd/ohp/pages/epsdt.aspx.

(4) The Authority and MCEs must cover Durable Medical Equipment for EPSDT Beneficiaries in accordance with sections (1) through (3) of this rule and OAR 410-122-0010 through OAR 410-122-0720.

(5) Providers must not refuse to render or refer for EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) care. Coverage decisions must be made by the Authority or the MCE in accordance with the requirements in sections (1) through (4) of this rule and any denial of coverage must be provided in writing by the Authority or the MCE in accordance with the requirements in OAR 410-151-0007.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 100-2025, minor correction filed 12/29/2025, effective 12/29/2025
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0003 Utilization Management Requirements

(1) The Oregon Health Authority (Authority) and Managed Care Entities (MCEs) do not have the right to pre-establish limits or caps on the amount of services or number of visits covered for EPSDT Beneficiaries. Instead, coverage decisions must be made in accordance with OAR 410-151-0002. However, it is acceptable to establish limits (for example, 10 physical therapy visits) subject to prior authorization for coverage of additional services.

(2) The Authority and MCEs do not have the right to require prior authorization for any EPSDT screening services.

(3) The Authority and MCEs shall promptly complete prior authorization procedures in accordance with OAR 410-141-3835 and OAR 410-130-0200 and the individual program chapter 410 and 309 OARs as applicable.

(4) The Authority and MCEs shall ensure prompt delivery of EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) services to EPSDT Beneficiaries.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0004 Screening Exams

(1) Periodic EPSDT screening exams shall be provided in accordance with the Bright Futures Periodicity Schedule (https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf) and must include:

(a) A comprehensive health and developmental history including assessment of both behavioral health and physical health development;

(b) Assessment of nutritional status;

(d) Appropriate immunizations;

(e) Lead testing as required by OAR 410-151-0040;

(f) Other appropriate laboratory tests (including but not limited to anemia test and sickle cell test) based on age and EPSDT Beneficiary risk;

(g) Health education including anticipatory guidance;

(h) Appropriate hearing and vision screening; and

(i) Dental examinations and assessments for preventative dental care, which must be performed in keeping with section (2) below of this rule.

(2) Periodic EPSDT examinations and assessments for preventive dental care shall be provided in accordance with the OHP Dental Periodicity Schedule, found at https://www.oregon.gov/oha/hsd/ohp/pages/policy-dental.aspx.

(a) Primary care providers that conduct oral health assessments must refer members to dental care professionals when needs are identified; and

(b) Prior authorization approvals are required for some services when benefit coverage limitations are age or dentition specific.

(3) EPSDT providers may bill for both lab and non-lab services using the appropriate Current Dental Terminology (CDT), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes. Immunizations must be billed according to the guidelines listed in OAR 410-130-0255.

(4) Inter-periodic EPSDT screening exams are any EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) encounters with a physician or other licensed practitioner of the healing arts within their scope of practice under State law. Inter-periodic EPSDT exams may occur at any time and may be warranted when the EPSDT Beneficiary has been ill or has experienced a change in health or development.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 23-2026, amend filed 06/05/2026, effective 06/05/2026
DMAP 5-2026, temporary amend filed 02/11/2026, effective 02/11/2026 through 08/09/2026
DMAP 114-2024, minor correction filed 07/19/2024, effective 07/19/2024
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0005 Referrals

(1) When a medical, behavioral health, nutritional, or dental condition is discovered during the EPSDT screening process, the EPSDT Beneficiary shall be referred to an appropriate provider for further diagnosis and, when EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate), receive treatment.

(2) The screening provider shall explain the need for the referral to the EPSDT Beneficiary, and, when applicable, the EPSDT Beneficiary’s parent or guardian.

(3) If the EPSDT Beneficiary, EPSDT Beneficiary’s parent, guardian, or legal authority agrees to the referral, the referring provider shall offer assistance in finding an appropriate referral provider and making an appointment.

(4) The EPSDT Beneficiary’s MCE or the Authority shall also make available care coordination as needed.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0006 Transportation and scheduling assistance

In accordance with the responsibilities in OAR 410-136-3000 Medical Transportation Services, the Authority or the MCE must offer and provide, when requested by the EPSDT Beneficiary or their parent or guardian:

(1) Transportation assistance to covered services;

(2) Scheduling assistance for appointments for covered services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0007 Notice and hearing requirements.

If the Authority or an MCE takes action to deny, suspend, reduce or terminate services for an EPSDT Beneficiary, it must provide the EPSDT Beneficiary, and, as applicable, the EPSDT Beneficiary’s parent or guardian, with a written notice that complies with the requirements in OAR 410-141-3885 and OAR 410-120-1865, which require, without limitation:

(1) A statement of the intended action and effective date;

(2) The specific reasons and legal support for the action;

(3) An explanation of the EPSDT Beneficiary’s appeal and hearing rights;

(4) The EPSDT Beneficiary’s rights to representation.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0008 EPSDT Beneficiary communication requirements

The Authority and MCEs must notify EPSDT Beneficiaries and, as applicable, the EPSDT Beneficiary’s parent or guardian, about services covered under EPSDT and how to access them, in accordance with a guidance document which became effective January 1, 2023 and is available at https://www.oregon.gov/oha/hsd/ohp/pages/epsdt.aspx. The notice must comply with the criteria for written materials set forth in OAR 410-141-3585 and be sent to EPSDT Beneficiaries and, as applicable, the EPSDT Beneficiary’s parent or guardian in accordance with the following timelines:

(1) Within sixty (60) days of an EPSDT Beneficiary enrolling in Oregon Health Plan (OHP) coverage;

(2) Immediately following birth for newborn infants; and

(3) Annually for any EPSDT Beneficiary who has not undergone an EPSDT screening or used other OHP services.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 99-2025, minor correction filed 12/29/2025, effective 12/29/2025
DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024

Or. Admin. R. 410-151-0040 Lead Screening

(1) All children enrolled in the Oregon Health Plan, including Fee-for-Service and MCEs, must have blood lead screening tests. Children with Medical Assistance Program coverage must have blood lead screening tests at age 12 months and 24 months. Any child between ages 24 and 72 months with no record of a previous blood lead screening test must receive one. Completion of a risk assessment questionnaire does not meet the lead screening requirement for children under Medicaid.

(2) Method of Blood Collection: A single venous or capillary blood draw is acceptable for the blood lead screening test. A capillary blood lead level greater than or equal to 3.5 micrograms per deciliter must be confirmed with either a venous draw or a second capillary draw within 12 weeks.

(3) Blood lead levels greater than or equal to 3.5 micrograms per deciliter from a venous draw or two capillary blood lead tests greater than or equal to 3.5 micrograms per deciliter drawn within 12 weeks of each other in children under 18 years of age and pregnant or lactating women are defined as cases and initiate case management by the local public health authority. See the definition of “Blood lead level at or above the blood lead reference value” in OAR 333-017-0000.

(4) Billing of laboratory services is covered in: OAR 410-130-0680.

(a) For the collection of blood, use CPT 36415 for a venipuncture sample or CPT 36416 for capillary puncture samples.

(b) To bill for venipuncture or capillary blood lead screening, use Current Procedural Terminology (CPT) code 83655.

(5) Health care providers shall report all cases or suspected cases when blood lead levels are at or above the blood lead reference value to local public health authority within one working day and within seven days when any blood lead level tests are performed including the result. See OAR 333-018-0015(3)(c)(A); OAR 333-018-0015(3)(d)

(6) All children, pregnant and lactating women with lead poisoning are eligible to receive follow up case management services. See OAR 333-019-0000 and Oregon Health Authority Public Health Division’s Oregon Lead Poisoning Investigative Guidelines at: https://www.oregon.gov/oha/PH/HealthyEnvironments/HealthyNeighborhoods/LeadPoisoning/CountyHealthDepartments/Documents/Diseaseguidelines.pdf.

(7) The local public health authorities are eligible for investigation reimbursements. To bill for comprehensive lead investigation, use HCPCS code T1029. Payment for code T1029 includes the home investigation and any follow-up case management services provided after the home investigation is completed. The Authority limits reimbursement of T1029 to one time per dwelling. For clients enrolled in Fee-for-Service, the service is payable by the Authority for dates of service through September 30, 2020. Effective October 1, 2020 for members enrolled in managed care plans, the service is payable by the managed care plan.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
DMAP 112-2024, adopt filed 07/11/2024, effective 07/11/2024

Division 152 Community Violence Prevention Services

Or. Admin. R. 410-152-0000 Purpose

(1) Community Violence Prevention services are evidence-based, trauma-informed, supportive, and non-psychotherapeutic services provided by a certified Violence Prevention Professional.

(2) Services are provided within or outside of a clinical setting for the purpose of promoting improved health outcomes and positive behavioral change, preventing injury, recidivism and reducing the likelihood that individuals who are victims of community violence may commit or promote violence themselves.

History

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session
Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065
DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024

Or. Admin. R. 410-152-0005 Violence Prevention Professional Certification Requirements.

To be certified as a Violence Prevention Professional, an individual shall:

(1) Be employed by a community-based organization who is enrolled with the Oregon Health Authority as a Medicaid billing provider. The community-based organization must also be affiliated with a licensed hospital in Oregon that authorizes the program to provide community violence prevention services to individuals in the hospital.

(2) Complete thirty-five (35) hours of initial training on trauma informed care, de-escalation, conflict mediation, retaliation prevention, case management, victim advocacy and patient privacy with an Oregon Health Authority approved training and certification program for violence prevention professionals in Oregon.

(3) Six (6) hours of Oregon Health Authority approved continuing education every two (2) years that must include effects of trauma and violence, trauma-informed care, case management and advocacy, community violence prevention strategies and patient privacy (HIPAA, 45 CFR parts 160 & 164)

(4) Have lived experience, either as a victim of a violent injury as a result of community violence or as someone closely impacted by community violence.

History

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session
Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065
DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024

Or. Admin. R. 410-152-0010 Definitions.

(1) “Authority” means the Oregon Health Authority.

(2) “Certification” means the national training and program credentials to be certified as a Violence Prevention Professional.

(3) “Certified Violence Prevention Professionals” mean mentors, violence interrupters, community members, credible messengers, advocates, and activists that have received certification through an Authority approved training and certification program.

(4) “Community Based Organization” means a public or private nonprofit organization that is representative of a community or significant segments of a community and provides educational or related services to individuals in the community. See section (16) of this rule..

(5) “Community Violence” means intentional acts of interpersonal violence committed by individuals who are not intimately related to the victim.

(6) “Community Violence Prevention Bundled Services” means the array of services included under one billing code. See OAR 410-152-0030.

(7) “Community Violence Prevention Services” means evidence-based, trauma-informed, supportive and non-psychotherapeutic services provided by a certified violence prevention professional in any appropriate setting, for the purpose of promoting improved health outcomes and positive behavioral change, preventing further injury and future violence.

(8) “Credible messengers” are individuals who can connect with and motivate at-risk people to successfully challenge and transform destructive thinking, attitudes, and actions.

(9) “Electronic signature” means an electronic sound, symbol or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record.

(10) “Hospital-based Violence Intervention Programs” are multidisciplinary programs that combine the efforts of medical staff with trusted community-based partners to provide safety planning, services, and trauma-informed care to violently injured people.

(11) “Individual” means a victim of community violence who is receiving services.

(12) “Intimate Partner Violence” means physical, sexual, or psychosexual harm by a current or former partner or spouse.

(13) “Licensed Practitioner of the Healing Arts” means a physician or other practitioner licensed in the State of Oregon who is authorized within the scope of the Licensed Practitioner of the Healing Art’s practice, as defined under state law, to diagnose and treat individuals with physical or mental disabilities or psychosocial, emotional, and behavioral disorders.

(14) “Multi-Disciplinary Care” is a collaborative approach to health care involving a diverse group of professionals working together to address all aspects of planning and ongoing care.

(15) “Plan of Care” means a presentation of information that easily describes the services and support being given to an individual.

(16) “Provider” means an organizational entity or qualified person that is certified to provide direct delivery of community violence prevention services.

(17) “Social Determinants of Health” means conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.

(18) “Supportive Services” means assistance to obtain medically appropriate and medically necessary services to address social determinates of health.

(19) “Trauma” means an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects of the individual’s functioning and physical, social emotional, or spiritual well-being.

(20) “Trauma Informed Care” (TIC) means an approach to the delivery of behavioral health services that includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. Trauma-informed care views trauma through an ecological and cultural lens and recognizes that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. TIC involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma. TIC upholds the importance of consumer participation in the development, delivery, and evaluation of services.

(21) “Victim” means a person who was physically or psychological injured because of community violence.

(22) “Wet signature” means the use of a physical signature, made by hand with a pen, to bind the party signing to the terms of the document upon which they leave their signature.

History

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session
Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065
DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024

Or. Admin. R. 410-152-0015 Community Violence Prevention Services.

(1) All Community Violence Prevention services provided by a community violence prevention program shall be performed by a certified Violence Prevention Professional.

(2) Community Violence Prevention services performed by a certified Violence Prevention Professional, shall be determined to be medically appropriate, medically necessary and appropriate for the individual’s age. Community Violence Prevention services may include based on the individualized plan of care:

(a) Conflict mediation;

(b) Crisis intervention;

(d) Peer support and counseling;

(e) Case management;

(f) Referrals to certified or licensed health care professionals or social service providers; or

(g) Screening services to victims’ community violence.

(3) Community Violence Prevention services shall be ordered or referred by a physician or other qualified licensed practitioner of the healing arts and shall be detailed in the individualized plan of care.

(4) The type, frequency, and quantity of units of Community Violence Prevention services authorized in the plan of care shall be appropriate for the individual’s age and designed to prevent further impacts of community violence, prevent future community violence, prolong life, and promote the physical and mental health and efficiency, of the individual.

(5) Providers are required to provide health care language interpreter services for Medicaid members with Limited English Proficiency (LEP) and communication services for people who are deaf and hard of hearing pursuant to Title VI of the Civil Rights Act, The Americans with Disabilities Act (ADA), ORS 413.550 to 413.558, and subject to the requirements in OAR Chapter 950 Division 50. These services must be provided at no cost to the member.

History

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session
Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065
DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024

Or. Admin. R. 410-152-0020 Documentation Requirements.

(1) The Plan of Care shall include the individuals need for: safety planning, interest in employment, housing, education, mental health and substance abuse treatment services, gang affiliation, legal needs and history of injury within the last six (6) months.

(2) Services rendered must be documented and signed, electronically or wet, by the certified Violence Prevention Professional rendering the service on each date of service.

(3) The provider shall maintain a record of each service provided to each eligible individual for each date of service including, but not limited to:

(a) Name and Medicaid identification number of individual receiving the service;

(b) Name and credentials of the certified Community Violence Prevention professional;

(d) Description of each service provided to the individual to address the psychosocial and safety needs of the client to include coordination of all services and interventions as developed in the individuals plan of care.

(e) Description of outcomes, including the individual’s responsiveness to services and any change in the frequency of: emergency room visits, retaliatory violence, arrest and acute stress and post-traumatic stress disorder.

(f) Document referrals to other identified services and supports, including referrals to entities completing eligibility assessments.

(4) The billing provider shall maintain adequate records for all Community Violence Prevention services rendered that fully supports the charges billed. Provider is responsible for the completeness, accuracy and secure storage of financial and clinical records and all other documentation of the specific care, service.

History

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session
Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065
DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024

Or. Admin. R. 410-152-0025 Eligibility Requirements.

(1) To be eligible to receive Community Violence Prevention services performed by a certified Violence Prevention Professional the individual shall:

(a) be enrolled in the Oregon Health Plan;

(b) have a history of injury sustained because of an act of community violence;

(c) received a recommendation for services by a physician or other qualified licensed practitioner of the healing arts within the practitioner’s scope of practice under the state law; and

(2) Individuals receiving Community Violence Prevention services shall have a plan of care in place that meets requirements described in section OAR 410-152-0030.

(a) The plan of care must be directed by the individual receiving Community Violence Prevention services; and

(b) The plan of care must be signed by the recipient of Community Violence Prevention services or a legal representative and the certified Violence Prevention Professional.

(c) The individual shall be re-assessed, and the plan of care shall be reviewed and updated by the certified Community Violence Prevention Professional every three months.

History

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session
Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065
DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024

Or. Admin. R. 410-152-0030 Limitations.

(1) Community Violence Prevention Services are not covered for individuals:

(a) Solely treated for intimate partner violence;

(b) Identified as a family member, friend, or associate of the individual receiving the service, and does not meet eligibility requirements described in OAR 410-152-0040

(2) Community Violence Prevention services are limited to eighteen (18) months of service per eligible incident for each individual. For each date of service, only those Community Violence Prevention services which are medically appropriate, included in the plan of care, and delivered to an Oregon Health Plan enrolled individual by an enrolled Community Violence Prevention Provider may be authorized.

(3) Community Violence Prevention services are mutually exclusive and shall be provided to one individual by one certified Violence Prevention Professional at a time. Provider shall not submit claims for Community Violence Prevention services that exceed a total of 24 hours per day or 365 days per calendar year, whether the services rendered by one Community Violence Prevention Professional or by several providers to the individual. The Authority may deny or recover overpayments from a provider for overlapping services, billing for unreasonable units of service over a span of time, unreasonable hours per day, and claims that lack adequate supporting documentation.

(4) The community-based organization that employees certified Violence Prevention Professionals must be affiliated with a licensed hospital in Oregon that authorizes the program to provide community violence prevention services to an individual in the hospital.

(5) Claims for Community Violence Prevention services to the Authority for payment may not duplicate other Oregon Health Plan covered services for the same individual at the same point in time.

(6) The provider shall bill the Authority according to the Community Violence Prevention bundled service code rather than itemizing the service under multiple codes. Providers may not “unbundle” services in order to increase the payment.

(7) Community Violence Prevention service shall not duplicate payments made to:

(a) A provider, public agencies or private entities for any other case management activities or covered services provided under the State Plan or Oregon Health Plan, through fee for service, managed care, or other contractual arrangement, that meet the same need for the same client at the same point in time;

(b) A provider by program authorities under different funding authority than Oregon Health Plan, including but not limited to grants and other public health funding;

(c) A provider for administrative expenditures reimbursed under agreement with the Authority or any other program or funding source.

(8) Community Violence Prevention services shall not be provided in lieu of medically necessary covered services.

(9) Community Violence Prevention services shall be age appropriate for the individual and shall be delivered by a certified Violence Prevention Professional with training in developmentally appropriate Community Violence Prevention services.

History

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session
Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065
DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024

Division 153 Certified Community Behavioral Health Clinics (CCBHC) Services

Or. Admin. R. 410-153-0000 Purpose and Scope

These rules define the requirements for Certified Community Behavioral Health Clinic (CCBHC) reimbursement through a bundled daily rate, cost reporting, rebasing, change in scope, and oversight for services provided to Oregon Health Plan members by CCBHCs certified by Oregon Health Authority under Oregon Administrative Rules chapter 309, division 009.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0005 Definitions

(1) “Access facility” means an outpatient setting owned and operated by a CCBHC and subject to approval by the Authority that provides low barrier services that facilitate engagement and access to care within the scope of CCBHC. Access facilities offer unscheduled, voluntary services.

(2) “Allowable Costs” means costs permitted under Oregon Health Authority’s (Authority) Certified Community Behavioral Health Clinic (CCBHC) Cost Report adherent to 45 CFR 75 (Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Services) and 42 CFR 412 (Principles of Reasonable cost Reimbursement).

(3) “Bundled Daily Rate” means a fixed daily, clinic-specific rate for all CCBHC services delivered during one calendar day.

(4) “Certified Community Behavioral Health Clinic (CCBHC)” means a provider organization that the Authority has affirmed that an organization substantially meets the federal and Oregon CCBHC standards “Oregon Certified Community Behavioral Health Clinic (CCBHC) Program Requirements Manual- Version 1” and requirements outlined in Oregon Administrative Rules (OAR) chapter 309 division 009.

(5) “CCBHC daily encounter” means one or more face-to-face or telephone contact between a health care professional and an individual receiving services within a 24-hour period ending at midnight as documented in the client’s record by the CCBHC or its Designated Collaborating Organizations in one calendar day. An encounter includes all eligible services, items, and supplies provided during the course of the visit.

(6) “Cost Report” means a financial report submitted by the CCBHC identifying total allowable costs and total CCBHC daily encounters for purposes of establishing and rebasing the bundled daily rate on a form designated by the Authority.

(7) “Designated Collaborating Organization” means a provider entity separate from the CCBHC which meets the requirements of OAR 410-153-0025 and is under contract with a CCBHC to deliver one or more required CCBHC services included in the bundled daily rate.

(8) “Medicare Economic Index (MEI)” means the inflation adjustment index applied annually to the CCBHC bundled daily rate.

(9) “Qualified satellite facility” means a facility that was established by the CCBHC, operated under the governance and financial control of that CCBHC, and provides the following services: crisis services; screening, diagnosis, and risk assessment; person and family centered treatment planning; and outpatient mental health and substance use services. This facility is included within the CCBHC certification is eligible for the daily bundled rate.

(10) “Rebase” means process for establishing a new bundled daily rate.

(11) “Required CCBHC services” means CCBHCs provide directly or through written Designated Collaborating Organization agreement all of the services defined in OAR 410-153-0020 section (2).

(12) “Scope of Service Change” means a change in the type, intensity, duration, or volume of CCBHC services that alters the bundled daily rate by at least 5 percent.

(13) “Third-Party Liability (TPL), Third-Party Resource (TPR), or Third-Party Payer (TPP)” means a medical or financial resource that, under law, is available and applicable to pay for medical services and items for an Authority client.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0010 Provider Requirements

(1) To qualify for payment under these rules, a provider must:

(a) Be certified by Oregon Health Authority (Authority) as a Certified Community Behavioral Health Clinic (CCBHC), Oregon Administrative Rule (OAR) chapter 309, division 009;

(b) Maintain an active Medicaid provider enrollment as required under OAR 410-120-1260;

(c) Meet all applicable state and federal Medicaid requirements for services, billing and payment, including but not limited to OAR chapter 410, division 120 and OAR chapter 410, division 141; Payment shall be made to a CCBHC only for services that are adequately documented; and

(d) Meet all the requirements of these rules, OAR chapter 410, division 153.

(2) CCBHCs must ensure that services are available to any individual eligible for services under their certification, regardless of ability to pay, consistent with OAR chapter 309, division 009.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0015 Eligibility and Enrollment Requirements

(1) Certified Community Behavioral Health Clinics (CCBHC) must:

(a) Be enrolled and have a signed provider enrollment agreement as a Medicaid provider prior to CCBHC certification;

(b) Obtain and maintain certification by Oregon Health Authority (Authority) Behavioral Health Division, as required by Oregon Administrative Rule (OAR) chapter 309, division 009;

(c) Obtain a National Provider Identification (NPI) number governed by OAR chapter 943, division 120 and OAR chapter 410, division 120;

(d) Complete provider enrollment forms as required by OAR 943-120-0300 through OAR 943-120-0320;

(e) Ensure all CCBHC service delivery locations and Designated Collaborating Organizations as described in section (2) below are enrolled as required under OAR 410-120-1260 and these rules, OAR chapter 410, division 153;

(f) Ensure all CCBHC facilities being enrolled are certified and approved in accordance with OAR 309-009-0030, including qualified satellite facilities and access facilities; and

(g) Submit a list of Designated Collaborating Organizations as described in section (2) below with submission of provider enrollment, when changes are made, or within 30 calendar days of written request by the Authority.

(2) A qualified satellite facility is a facility owned and operated by a CCBHC that does not provide all required services but provides at minimum: crisis services, except mobile crisis; screening, diagnosis, and risk assessment; service planning; and outpatient mental health and substance use services within the scope of the CCBHC. This facility is included within the CCBHC certification is eligible for the daily bundled rate.

(a) Qualified satellite facilities must be certified and approved by the Behavioral Health Division under OAR division 309 chapter 009

(b) CCBHCs must ensure individuals receiving services at qualified satellite facilities have access to CCBHC services not provided at the qualified satellite facility;

(d) CCBHCs must notify the Authority of intent to add qualified satellite facilities, apply for certification of qualified satellite facility, and complete a change in scope if applicable.

(3) An access facility is an outpatient setting owned and operated by a CCBHC and subject to approval by the Authority that provides low barrier services that facilitate engagement and access to care within the scope of CCBHC. Access facilities offer unscheduled, voluntary services and are differentiated from CCBHC satellite facilities which must provide a set of required services.

(a) Access facilities must be certified and approved by the Behavioral Health Division under OAR division 309 chapter 009;

(b) CCBHCs must ensure individuals receiving services at access facilities have access to CCBHC services provided at approved CCBHC facilities;

(d) CCBHCs must notify the Authority of intent to add access facilities, apply for approval of access facilities, and complete a change in scope if applicable.

(4) The CCBHC must notify the Authority in writing within 90 calendar days of adding or eliminating any of the required CCBHC services outline in OAR 410-153-0020, opening or closing a service site, or a change in ownership interest. The CCBHC must notify the Authority in writing within 90 calendar days of any change to a qualified satellite facility or Designated Collaborating Organization including adding or eliminating any of the required CCBHC services outline in OAR 410-153-0020, opening or closing a service site, or a change in ownership interest.

(5) Loss of CCBHC certification under OAR chapter 309 division 009 immediately terminates eligibility for bundled daily rate payment.

(6) CCBHC failure to maintain Medicaid enrollment may result in recoupment of improper payments or other sanctions consistent with OAR 410-120-1395 through OAR 410-120-1460.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0020 Required Services

(1) Certified Community Behavioral Health Clinics (CCBHC) must follow the Oregon Administrative Rules (OAR) chapter 410, division 120 and division 141 coverage rules applicable to each service in section (2) below.

(2) CCBHCs are reimbursed by the Authority through the bundled daily rate for qualifying CCBHC services including:

(a) 24-hour crisis behavioral health services, including mobile crisis outreach;

(b) Screening, assessment, and diagnosis;

(d) Outpatient mental health and substance use disorder services;

(e) Primary care screening and monitoring;

(f) Targeted case management;

(g) Psychiatric rehabilitation services;

(h) Peer and family support services;

(i) Intensive, community-based mental health care for members of the armed forces and veterans.

(3) Services provided by a Designated Collaborating Organization must comply with standards outlined in OAR chapter 309, division 019 and other applicable Medicaid coverage guidelines in OAR chapter 410, division 120 and division 141.

(4) CCBHCs must provide all required services directly or through written formal Designated Collaborating Organization agreements.

(5) CCBHCs must develop and maintain adequate financial and clinical records and other documentation that supports the specific care, items, or services for which payment has been requested.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0025 Designated Collaborating Organization

(1) Designated Collaborating Organization are entities that are not under the direct supervision of a CCBHC but engage in a contractual agreement with a Certified Community Behavioral Health Clinic (CCBHC) to provide CCBHC services.

(2) Designated Collaborating Organizations must be appropriately licensed and certified by Oregon Health Authority (Authority) to provide services they are contracted to provide.

(3) Services provided by the Designated Collaborating Organization must meet the same standards as the CCBHC as outlined in Oregon Administrative Rules (OAR) chapter 309, division 009 for the services they are providing.

(4) Designated Collaborating Organization arrangements must be evidenced by a legally binding document.

(5) The CCBHC must pay for the services provided by the Designated Collaborating Organization at daily bundle rate with exception to state-sanctioned mobile crisis services. As such:

(a) Costs associated with the provision of the services for the Designated Collaborating Organization must be reported in the cost report.

(b) CCBHC daily encounters from the Designated Collaborating Organization must be reported in the cost report.

(c) The CCBHC and Designated Collaborating Organization must have policies and procedures outlining how the Designated Collaborating Organization will avoid duplication of payment.

(6) Designated Collaborating Organization are required to provide CCBHCs with the data needed to calculate CCBHC daily encounters, cost of services, and any related data reporting and quality metrics.

(7) Designated Collaborating Organizations are required to provide services on behalf of the CCBHC in accordance with CCBHC rules and regulations and defined in OAR chapter 309, division 009.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0030 Eligibility for Payment

(1) Certified Community Behavioral Health Clinics (CCBHC) must bill the clinic-specific bundled daily rate when at least one qualifying CCBHC service, as these services are described in Oregon Administrative Rules (OAR) 410-153-0020, is provided by the CCBHC or Designated Collaborating Organization to an Oregon Health Plan member (OHP).

(2) Only one bundled daily rate is permitted to be paid per OHP member per calendar day, regardless of the number of services or provider contacts.

(3) Services rendered by Designated Collaborating Organizations must be included within the CCBHC’s bundled daily rate and billed by the CCBHC, not separately by the Designated Collaborating Organization.

(4) Only services provided at approved CCBHC facilities are eligible the bundled daily rate.

(5) Telephone CCBHC daily encounters qualify as a valid CCBHC daily encounter for services provided in accordance with OAR 410-120-1990.

(6) Claims must include ICD-10-CM and CPT/HCPC codes as required by OAR 410-120-1280.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0035 Bundled Daily Rate Establishment

(1) Oregon Health Authority (Authority) establishes an initial interim bundled daily rate for each Certified Community Behavioral Health Clinic (CCBHC) based on projected allowable costs and projected CCBHC daily encounters or based on payments to the nearest cost center with a similar caseload in the event that the Authority determines such methodology is more appropriate.

(2) Allowable costs are based on:

(a) Direct service costs, including salaries, benefits, contracted services, and supplies directly tied to delivering CCBHC services;

(b) Allocated administrative and facility overhead costs, consistent with 2 CFR Part 200 and Centers for Medicaid and Medicare Services (CMS) cost principles.

(3) The interim bundled daily rate is calculated by the Authority as:

(a) Total projected allowable costs divided by total projected Medicaid and non-Medicaid CCBHC daily encounters;

(b) Adjusted for Medicaid utilization projections if required by CMS guidance.

(4) Each CCBHC’s interim rate must be effective on the date of initial certification and enrollment approval, or such other date as determined by the Authority.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0040 Cost Reporting Requirements

(1) Each Certified Community Behavioral Health Clinic (CCBHC) must submit a cost report on forms prescribed by Oregon Health Authority (Authority), identifying:

(a) Total allowable direct and indirect costs; and

(b) Total number of Medicaid and non-Medicaid CCBHC daily encounters.

(2) The CCBHC must submit cost reports no later than 120 days after the close of the CCBHC's fiscal year on rebase years, unless an extension is granted in writing by the Authority. In addition, new CCBHCs must submit a cost report to the Authority after the first 12 months of operation to establish an updated rebased rate.

(3) Cost reports submitted by the CCBHC must be based on accrual accounting methods unless a waiver is approved in writing by the Authority.

(4) Failure to submit a completed and timely cost report may result in suspension of payment or other sanctions under Oregon Administrative Rules (OAR) 410-120-1395 through OAR 410-120-1460.

(5) The Authority may request an updated cost report from a CCBHC when the CCBHC has an interruption in operations, whether this is due to suspension or termination of the CCBHC’s Oregon Health Plan enrollment or certification or other reasons.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0045 Cost Reconciliation and Settlement

(1) Oregon Health Authority (Authority) performs reconciliation following the establishment of a new bundled daily rate by comparing payments made under previous bundled daily rate to newly established bundled daily rate.

(2) If the payments made to a Certified Community Behavioral Health Clinic (CCBHC) provider exceed the newly established bundled daily rate, the Authority must recoup the overpayment for period following the close of the cost reporting period and establishment of new rate.

(3) If the payments made to a CCBHC provider are less than newly established bundled daily rate, the Authority may issue a settlement payment to the CCBHC for the period following the close of the cost reporting period and establishment of a new bundled daily rate.

(4) All settlements are subject to audit and final determination by the Authority. The CCBHC may appeal the Authority’s determination, as outlined in Oregon Administrative Rules 410-153-0090.

(5) Settlements are completed by the Authority within 18 months of the close of the cost report year, unless delayed by circumstances beyond the Authority’s control.

(6) Payment or settlement by the Authority does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit a claim before or after the payment. Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the service was not provided in accordance with applicable rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0050 Scope of Service Changes

(1) A Certified Community Behavioral Health Clinic (CCBHC) may submit a written request to the Oregon Health Authority (Authority) for an adjustment to its bundled daily rate if there is a documented scope of service change that results in at least a five (5) percent change in cost per encounter.

(2) A CCBHC scope change request must include for each change for which the CCBHC is requesting an adjustment:

(a) A detailed description of the change in services, staffing, or operations;

(b) Supporting financial data showing the projected cost impact of each change;

(3) If approved by the Authority, the rate adjustment is effective on the first day of the calendar quarter following the date of the Authority’s approval.

(4) A CCBHC may request a scope of service adjustment no more than once per calendar year, unless the Authority determines that multiple unrelated changes have occurred.

(5) The Authority will begin its review of a CCBHC scope change request when all data and information required by section (2) above has been received by the Authority. The Authority may also request additional data or information from the CCBHC in the course of its review, as the Authority deems necessary. All such requests will be provided in writing to the CCBHC.

(6) CCBHC scope changes may include but are not limited to:

(a) Changes in the type, intensity, or duration of covered services required under the CCBHC;

(b) Expansion or reduction of operational hours for services;

(d) Changes in cost resulting from state or federal regulatory or statutory requirements.

(7) CCBHC changes that do not generally qualify as a scope of service change include:

(a) Routine fluctuations in encounter volume;

(b) Changes in payer mix without associated scope changes;

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0055 Rebasing Requirements

(1) Oregon Health Authority (Authority) must rebase each Certified Community Behavioral Health Clinic’s (CCBHC) bundled daily rate no less frequently than once every two (2) years based on finalized cost reports and actual encounter data.

(2) The Authority’s rebasing calculations considers the:

(a) Total allowable costs for the rebasing year;

(b) Total Medicaid and non-Medicaid encounters for the rebasing year;

(3) New CCBHCs must submit a cost report to the Authority after the first 12 months of operation to establish an updated rebased rate.

(4) The Authority may stagger rebasing schedules to balance administrative workload, but no CCBHC shall go longer than two (2) years without a rebasing unless authorized by CMS.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0060 Annual Inflation Adjustment Using MEI

The Authority will adjust for inflation annually, trending each clinic-specific from the mid-point of the previous calendar year to the midpoint of the following year using the Medicare Economic Index (MEI).

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0065 Coordinated Care Organization (CCO) Payments and Supplemental (Wraparound) Payments

(1) Certified Community Behavioral Health Clinics (CCBHCs) must bill the applicable CCO for services provided to members enrolled in a CCO. CCOs are not required to pay CCBHCs at their bundled daily rate.

(2) CCBHCs may receive supplemental Medicaid wraparound payments to ensure that total reimbursement for CCBHC daily encounters for CCO-enrolled members and dual-eligible members meets the bundled daily rate.

(3) Oregon Health Authority (Authority) calculates the supplemental payments on a quarterly basis using the “CCBHC Wraparound Data Template” and “CCBHC Wraparound Guide” found on the CCBHC website. Calculations are based on:

(a) Costs incurred during the settlement period;

(b) Amounts received during the settlement period;

(4) CCBHC must submit wraparound reports within 12 months of close of quarter being reported. Exceptions to the 12-month requirement that are permitted to be submitted to the Authority are as follows:

(a) When Oregon Department of Human Services (ODHS), the Authority, or the member’s branch office makes an error that causes the provider not to be able to bill within 12 months of the date of service, the report is permitted to be filed up to six (6) months after the error is discovered. The Authority must confirm the error.

(b) When a court or an Administrative Law Judge orders the Authority to make payment.

(5) The Authority must issue supplemental payments within 90 days of receipt of complete and accurate quarterly reports.

(6) CCBHCs must retain supporting documentation for all CCO encounters and payments for a minimum of 10 years for audit purposes.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0070 Fee-for-Service Payments

Certified Community Behavioral Health Clinics (CCBHC) must bill the Oregon Health Authority directly for CCBHC daily encounters with fee-for-service Oregon Health Plan members using the clinic's bundled daily rate.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0075 CCBHC Daily Encounter Definitions and Billing

(1) A Certified Community Behavioral Health Clinic (CCBHC) submitting a claim or other request for payment to Oregon Health Authority (Authority) or a Coordinated Care Organization (CCO) must meet the requirements in Oregon Administrative Rules (OAR) 410-153-0010, OAR 410-120-1280 and OAR 410-120-1300.

(2) Only one CCBHC daily encounter is permitted to be paid per Oregon Health Plan member per calendar day, regardless of the number of services rendered.

(3) Covered services provided by a CCBHC or Designated Collaborating Organization via telehealth may qualify as encounters if the services meet federal and state telehealth standards and are documented appropriately. Services within the scope of CCBHC delivered via telehealth must be billed at the daily encounter rate and are not eligible to be billed separately.

(4) Ancillary services (for example, laboratory tests, basic imaging) provided in connection with a same-day CCBHC service are included in the CCBHC daily encounter and not separately billable.

(5) CCBHCs must list all applicable billing modifiers on the claim.

(6) Before billing the Authority or a CCO, a CCBHC must make reasonable efforts to obtain payment first from other resources as required under OAR 410-120-0080.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0080 Program Integrity and Audit Compliance

(1) Certified Community Behavioral Health Clinics (CCBHC) are subject to audits and other reviews by the Oregon Health Authority (Authority) under Oregon Administrative Rules (OAR) chapter 410, division 120.

(2) The CCBHC must submit true, accurate, and complete claims. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certification by the CCBHC.

(3) The CCBHC must maintain complete and accurate service and financial records supporting:

(a) All encounters billed to Medicaid and Medicare;

(b) Cost reports submitted to the Authority;

(d) All services provided and payments received.

(4) The Authority may at any time conduct audits, desk reviews, or on-site inspections of the CCBHC and any Designated Collaborating Organization, to verify CCBHC compliance with these rules, OAR chapter 410, division 120, and OAR chapter 410, division 141.

(5) CCBHCs must cooperate fully with audits and investigations conducted by the Authority, Centers for Medicare and Medicaid Services, Medicaid Fraud Control Unit, or other authorized federal and state agencies as required under OAR 410-120-1395, OAR 410-120-1396, and OAR 410-120-1510.

(6) If a CCBHC determines that a submitted claim, cost report, or wrap payment received from the Authority or a CCO is an overpayment, the CCBHC must refund the amount of the overpayment to the Authority or the CCO, as required under OAR 410-120-1280 or the CCBHC’s contract with the CCO.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Or. Admin. R. 410-153-0085 Appeals

(1) Certified Community Behavioral Health Clinics (CCBHC) may appeal Oregon Health Authority (Authority) adverse actions relating to bundled daily rate setting, cost reconciliation, scope of service adjustments, or supplemental payment determinations.

(2) CCBHC appeals of an Authority decision must be made in writing and filed with the Authority consistent with the procedures in Oregon Administrative Rules (OAR) 410-120-1560 to OAR 410-120-1600. CCBHC appeals of a CCO decision must be filed with the CCO.

(3) The CCBHC’s appeals must:

(a) Be filed timely, as required under OAR 410-120-1560;

(b) Clearly identify the action being appealed;

(d) Include supporting documentation.

(4) The Authority must issue a final order in contested case proceedings consistent with applicable Oregon Administrative Procedures Act (APA) requirements and OAR chapter 410, division 120.

(5) CCBHC may appeal other Authority determinations as outlined in OAR chapter 410, division 120.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025

Division 155 Reentry Health Care Program

Or. Admin. R. 410-155-0000 Acronyms and Definitions

(1) “Adjudication” is when a court process has determined that the eligible individual committed the charged act and the court ordered the eligible individual be held in custody as part of the disposition of the charges.

(2) “Correctional Facility” means, for the purpose of providing required Reentry FCAA Services, state prisons, county or regional jails, tribal jails and prisons, juvenile detention, or state youth correctional facility.

(3) “2023 Federal Consolidated Appropriations Act (FCAA)” means the federal spending law (P.L. 117-328) that requires relevant Reentry FCAA Services to be provided to FCAA-Covered Youth.

(4) “FCAA-Covered Youth” means Medicaid or CHIP-enrolled youth who are either under age 21, or determined eligible for the mandatory former foster care Medicaid eligibility group, as described in OAR 410-200-0407, and are held, or have been held in a correctional facility post-adjudication, and who otherwise meet all other applicable eligibility criteria as defined in section 5121 of the 2023 FCAA.

(5) “Post-Release Case Manager” means a Provider who meets the Reentry Targeted Case Management provider qualifications and is responsible for providing targeted case management services to FCAA-Covered Youth for at least thirty (30) days after such Youth is released to the community as described in OAR 410-138-0060.

(6) “Post-Release Period” refers to the thirty (30) day time period following an FCAA-Covered Youth’s release from a Correctional Facility.

(7) “Pre-Release Case Manager” means a provider who meets the Reentry Targeted Case Management provider qualifications described in OAR 410-138-0060 and provides, in accordance with Reentry FCAA Services, reentry targeted case management services to the FCAA-Covered Youth during their Pre-Release Period.

(8) “Pre-Release Period” refers to the thirty (30) day time period prior to an FCAA-Covered Youth’s expected release from a Correctional Facility.

(9) “Reentry Care Plan and (RCP)” each mean the case management activity to document goals and actions (e.g., referrals, appointment scheduling) the case manager identified with the FCAA-Covered Youth to address the medical, mental, substance use, housing and other health-related social needs (HRSN), functional needs, and strengths and support resources needed by the FCAA-Covered Youth.

(10) “Reentry FCAA Services” means the defined set of existing Medicaid and CHIP services that must be provided to FCAA-Covered Youth, as required under Section 5121 of the 2023 Federal Consolidated Appropriations Act (FCAA). Services include:

(a) Screening and diagnostic services in the thirty (30) days prior to release, or no later than one week, or as soon as practicable, after release; and

(b) Targeted case management in the thirty (30) days prior to release and for at least thirty (30) days post-release (as defined in OAR 410-138-0000).

(11) “Reentry Health Risk Assessment” and “Reentry (HRA)" each mean a comprehensive assessment gathered from the FCAA-Covered Youth and other sources, such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the FCAA-Covered Youth. The Reentry HRA includes identifying and documenting the FCAA-Covered Youth’s needs including the extent and nature of the FCAA-Covered Youth’s needs as they return to the community.

(12) “Reentry Warm Handoff” is a required transition meeting attended by the Pre-Release Case Manager, Post-Release Case Manager, and the FCAA-Covered Youth when the Pre-Release Manager and Post-Release Case Managers are different in order to ensure a supportive reentry process, continuity of case management, and follow-up as the FCAA-Covered Youth transitions into the community.

History

Statutory/Other Authority: (CAA, 2023) (P.L. 117-328)
Statutes/Other Implemented: (CAA, 2023) (P.L. 117-328)
DMAP 98-2025, adopt filed 12/29/2025, effective 01/01/2026

Or. Admin. R. 410-155-0010 Eligibility Criteria and Service Requirements

The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering and delivering Reentry FCAA Services, identified below.

(1) Reentry FCAA Services must be provided to FCAA-Covered Youth in accordance with Section 5121 of the Federal Consolidated Appropriations Act of 2023 (CAA, 2023) (P.L. 117-328).

(2) The Authority shall monitor Correctional Facility delivery of Reentry FCAA Services in the Pre-Release Period.

(3) The Oregon Health Plan (OHP) shall cover Reentry FCAA Services provided in the Post-Release Period.

(4) The Authority or the Managed Care Entity (MCE) must document when they receive notice (from sources such as ODHS, the Authority, Correctional Facilities, OHP application assisters) of an FCAA-Covered Youth’s release from a Correctional Facility.

(5) OHA payment to MCEs for FCAA Reentry Services as defined in OAR 410-155-0000(5) and in the CCO Reentry Guidance Document is included in the Global Budget.

(6) The Authority or the MCE shall provide the following Reentry FCAA Services in the Post-Release Period:

(a) Screening and Diagnostic Services shall be provided within one (1) week, or as soon as practicable, after the FCAA-Covered Youth’s release from a Correctional Facility by a Medicaid-enrolled physician (MD or DO), nurse practitioner, licensed physician assistant, or other licensed health professional.

(A) Services must meet Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) standards as defined in OAR 410-151-0004, 410-151-0040 for screening exams and OAR 410-151-0004(1) for diagnostic services.

(B) Screening Services, in accordance with requirements in Section 1905(r)(1)-(4) of the Social Security Act (42 U.S.C §§ 301-1307), must include, at a minimum: comprehensive health and developmental history, including assessment of both physical and mental health development, comprehensive unclothed physical examinations, appropriate vision and hearing test, appropriate laboratory tests, and dental screening services.

(C) Diagnostic services, in accordance with section 1905(r)(5) of the SSA, must include diagnosis of defects in vision and hearing, dental care, and appropriate immunizations.

(D) For FCAA-Covered Youth enrolled in the Children’s Health Insurance Program (CHIP), benefit must include similar screening and diagnostic services, but only to the extent such services would normally be covered for a non-incarcerated youth.

(E) For FCAA-Covered Youth 21 years of age and older, services must be provided based on reasonable standards of medical and dental practice.

(F) If efforts to deliver screening or diagnostic services are unsuccessful, or if the FCAA-Covered Youth declines to receive these services, the MCE or as applicable, the Authority must document:

(i) That the MCE or as applicable, the Authority made at least two (2) attempts to conduct outreach to the FCAA-Covered Youth, including identifying the specific attempts and barriers to outreach; and

(ii) The FCAA-Covered Youth’s reasons for rejecting screening and diagnostic services to the maximum extent feasible.

(G) The MCE or as applicable, the Authority must conduct outreach to the FCAA-Covered Youth to facilitate the delivery of screening and diagnostic services within the timeframe stated above in 6(a).

(H) The MCE or as applicable, the Authority is responsible for documenting, and maintaining such documentation, that FCAA-Covered Youth have been provided with screening and diagnostic services.

(b) Reentry Targeted Case Management (TCM) as defined in OAR 410-138-0000 shall be provided within the Post-Release Period by a Medicaid-enrolled Post-Release Case Manager as defined in OAR 410-155-0000.

(A) Completion of the Reentry Health Risk Assessment (Reentry HRA) that includes:

(i) The Post-Release Case Manager must complete the Reentry HRA with the FCAA-Covered Youth within thirty (30) days of the FCAA-Covered Youth’s release from a Correctional Facility; and

(ii) The Reentry HRA shall be developed with and agreed upon by the FCAA-Covered Youth, the FCAA-Covered Youth’s guardian, or both, as applicable, and documented in the FCAA-Covered Youth’s health records.

(iii) The Reentry HRA must include all of the following elements:

(I) Taking FCAA-Covered Youth’s history and gathering available information from other sources such as family members, medical providers, social workers, Correctional Facility where the FCAA-Covered Youth was incarcerated, including from any assessments completed by the Correctional Facility, and educators (if necessary), to form a complete assessment of the FCAA-Covered Youth; and

(II) Screening for medical, mental, substance use, housing and other health-related social needs (HRSN), functional needs, and strengths and support needs.

(iv) The Post-Release Case Manager is responsible for all Reentry HRA documentation, including documentation of:

(I) At least one face-to-face or telehealth encounter/assessment with the FCAA-Covered Youth by the Post-Release Case Manager. This encounter must include either direct screening and/or assessments in accordance with subsection (a) above, or review with the FCAA-Covered Youth of any prior assessments through prior medical record review and other documentation review with identification of new or resolved needs or the documentation of no new additional needs. This could occur over multiple visits/encounters, as needed.

(II) Reentry goals and objectives based on the Reentry HRA. This can be included as part of the same documentation of the Reentry HRA or can be a separate document. This must be developed with and informed by the FCAA-Covered Youth.

(v) If efforts to have a meeting are unsuccessful, or if the FCAA-Covered Youth declines to participate in the development of the Reentry HRA but the FCAA-Covered Youth is eligible to receive Reentry FCAA Services and wishes to accept these services, they are still entitled to receive the Reentry FCAA Services as medically appropriate. In all such circumstances, the MCE or as applicable, the Authority must document:

(I) That the Post-Release Case Manager made efforts to have one or more meetings with the FCAA-Covered Youth, including identifying the specific attempts and barriers to having the meetings; and

(II) The FCAA-Covered Youth’s reasons for not participating in the Reentry HRA to the maximum extent feasible.

(B) Completion of the Reentry Care Plan (RCP)

(i) The Post-Release Case Manager must complete the Reentry Care Plan with the FCAA-Covered Youth within thirty (30) days of the FCAA-Covered Youth’s release from a Correctional Facility.

(ii) The Reentry Care Plan must be developed with and agreed upon by the FCAA-Covered Youth, the FCAA-Covered Youth’s guardian, or both, as applicable, and documented in the FCAA-Covered Youth’s health records.

(iii) Post-Release Case Managers must ensure the Reentry Care Plan includes all elements required in OAR 410-141-3870, with the additional elements listed below in (I)-(III), based on information collected through the HRA:

(I) Specifies the goals and actions needed to address the medical, mental, substance use, housing and other HRSN, functional needs, and strengths and support needs of the FCAA-Covered Youth such as developing safe decision-making skills or building relationships.

(II) Includes referral and related activities such as scheduling appointments for the FCAA-Covered Youth, and working with the FCAA-Covered Youth’s (or the FCAA-Covered Youth’s authorized health care decision maker) and others to develop those goals.

(III) Identifies a course of action to respond to the goals and proposed actions of the FCAA-Covered Youth.

(iv) If efforts to have a meeting are unsuccessful, or if the FCAA-Covered Youth declines to participate in the development of the Reentry Care Plan, but the FCAA-Covered Youth wishes to accept Reentry FCAA Services, they are still entitled to receive the Reentry FCAA Services in the Post-Release Period as medically appropriate. In all such circumstances, the MCE or as applicable, the Authority must document:

(I) That the Post-Release Case Manager made efforts to have one or more meetings with the FCAA-Covered Youth, including identifying the specific attempts and barriers to having the meetings;

(II) The FCAA-Covered Youth’s reasons for not participating in the Reentry Care Plan to the maximum extent feasible.

(C) The MCE or as applicable, the Authority is responsible for documenting, and maintaining such documentation, that FCAA-Covered Youth have been provided with Reentry TCM services.

(D) Completion of the Reentry Warm Handoff within thirty (30) days of a FCAA-Covered Youth’s release from a Correctional Facility if the FCAA-Covered Youth received Reentry TCM in the pre-release period and was assigned a Pre-Release Case Manager. To complete a Reentry Warm Handoff with the Pre-Release Case Manager, the Post-Release Case Manager must:

(i) Reach out to Correctional Facility and request relevant health information; and

(ii) Conduct the Reentry Warm Handoff meeting, either in-person or via telehealth, with the FCAA-Covered Youth and the Pre-Release Case Manager, unless the FCAA-Covered Youth refuses to participate.

(iii) During the Reentry Warm Handoff, the Pre-Release Case Manager and/or the Correctional Facility must share correctional health records and any other information related to the FCAA-Covered Youth’s care, with the Post-Release Case Manager as appropriate and necessary for the care of the FCAA-Covered Youth.

History

Statutory/Other Authority: (CAA, 2023) (P.L. 117-328)
Statutes/Other Implemented: (CAA, 2023) (P.L. 117-328)
DMAP 98-2025, adopt filed 12/29/2025, effective 01/01/2026

Division 160 LAW ENFORCEMENT LIABILITY ACCOUNT (LEMLA)

Or. Admin. R. 410-160-0000 Definitions

For the purposes of OAR 410-160-0000 through 410-160-0100, the following definitions shall apply:

(1) LEMLA means the Law Enforcement Medical Liability Account.

(2) LEMLA Patient means a person who has suffered injuries related to law enforcement activity.

(3) Injuries Related to Law Enforcement Activity means injuries sustained prior to booking, citation in lieu of arrest or release instead of booking that occur during and as a result of efforts by a law enforcement officer to restrain or detain, or to take or retain custody of, the individual. Whether injuries related to law enforcement activity have occurred shall be determined by the law enforcement agency.

(4) Release Date means the date the LEMLA patient was released from actual physical custody, as determined by the law enforcement agency.

(5) Cost of Such Services means "usual charge" as defined in OAR 410-120-0000.

(6) Hospital means a hospital as defined in OAR 410-120-0000.

(7) Overpayment means payment made by LEMLA to a claimant in excess of the amount due for the covered services and items billed.

(8) Claimant means a Medicaid provider.

(9) Medicaid Provider means a provider who has been issued a provider number by the Division and is not currently subject to sanction by the Division.

(10) Prior Payment Amount means the total of all payments received by the claimant from all other sources, including the LEMLA patient, prior to submitting a LEMLA claim.

(11) LEMLA Claim Amount means the total cost of such services provided to a LEMLA patient that are directly connected to injuries related to law enforcement activity. It shall not include any charges for services provided to a LEMLA patient for a preexisting disease or condition, or services that are unrelated to the "injuries related to law enforcement activities."

History

Statutory/Other Authority: ORS 413-042 & ORS 414.065
Statutes/Other Implemented: ORS 414.805 — ORS 414.815
Renumbered from 461-012-0100, DMAP 9-2011, f. 6-6-11, cert. ef. 7-1-11
AFS 10-2002, f. & cert. ef. 7-1-02
AFS 24-1993, f. 10-27-93, cert. ef. 11-1-93
AFS 6-1992, f. & cert. ef. 3-9-92
AFS 1-1992, f. 1-14-92, cert. ef. 2-1-92

Or. Admin. R. 410-160-0100 Process and Procedure

(1) The purpose of the Law Enforcement Medical Liability Account (LEMLA) is to provide a fund to reimburse a claimant for emergency medical services provided to a LEMLA patient.

(2) The time limit for submitting claims to LEMLA is one year after the date of injury. If a claimant has been paid by a LEMLA patient's insurer or health care contractor and the LEMLA patient's insurer or health care contractor subsequently demands return of the payment, a claimant must bill LEMLA not later than 180 days from the date of the demand letter or one year from the date of injury, whichever is later.

(3) The Division shall process all claims received in accordance with the following procedures:

(a) The claim shall be date stamped on the date received by LEMLA;

(b) The Division shall review each claim submitted to verify that the claim contains all of the following required information:

(A) The LEMLA claim form, with the following information:

(i) Certification by an authorized representative of the law enforcement agency involved with an injury that the injury is related to law enforcement activity;

(ii) The release date, if any, as determined by the law enforcement agency. If the LEMLA patient has not yet been released, state that on the LEMLA claim form;

(iii) LEMLA patient's name;

(iv) Prior payment amount;

(v) Date of injury;

(vi) Claimant's Medicaid provider number;

(vii) Claimant's name;

(viii) LEMLA claim amount;

(ix) Cause or nature of injury.

(B) Attached to the LEMLA form, the following information:

(i) Documentation that demonstrates the claimant has billed the LEMLA patient or the LEMLA patient's insurer or health care contractor for the charges or expenses owed to the claimant and that the claimant has made a reasonable effort to collect from the LEMLA patient or the LEMLA patient's insurer or health care contractor;

(ii) A copy of the hospital or provider billing document that shows the usual charge and date of service.

(c) The Division shall reject claims that do not contain all of the information required in subsection (3)(b) of this rule;

(d) The Division shall review the documentation of reasonable collection effort. If 45 days have not elapsed since the claimant billed the LEMLA patient or the LEMLA patient's insurer or health care contractor, the claim may be rejected;

(e) The Division shall review the date of injury. If the date stamped on the claim under subsection (3)(a) of this rule is more than one year after the date of injury, the claim shall be rejected. The one-year time limit may not apply if the provisions of section (2) of this rule apply with regards to an insurer or health care contractor demanding repayment of a previously paid claim.

(4) Using the LEMLA claim amount, the Division shall pay claimants, subject to any adjustment made under section (5) of this rule, according to the following:

(a) For hospitals, by the current "Hospital Fee Schedule-Adjusted Cost/Charge Ratios for Oregon Hospitals," established by the Director of the Department of Consumer and Business Services;

(b) For all Medicaid providers except hospitals, the Division shall pay 75 percent of the LEMLA claim amount.

(5) After determining the amount under section (4) of this rule, the Division shall add the amount received in section (6) of this rule. If the total is more than the usual charge, the Division shall reduce the amount of its payment by the amount in excess of the usual charge.

(6) The claimant is responsible for making reasonable effort to collect from the LEMLA patient or the LEMLA patient's insurer or health care contractor. Claimants are required to report all collections made when a claimant submits a claim to the Division for payment.

(7) If the Division has paid a claimant and the claimant subsequently receives payment from any other source, the claimant is required to repay the Division the amount received, minus the difference between the usual amount billed and the amount the Division paid. This means claimants are entitled to reimburse themselves for the amount the Division did not pay, with the excess due to the Division as repayment of an overpayment. The repayment is due and payable by check to the Division within 30 days after the claimant has received the funds from the other source.

(8) The Division shall continue to pay for medical services for injuries related to law enforcement activities while the LEMLA patient is incarcerated. Upon release of the LEMLA patient from physical custody, the Division shall no longer pay for further medical expenses incurred. If the LEMLA patient is cited in lieu of arrest or released instead of booked, the Division shall no longer pay for further medical expenses upon discharge or release from the hospital or other medical facility.

(9) The Division shall pay all accepted claims to the extent that the Division has sufficient funds available, subject to the maximum limit for payment of expenses authorized by law. The Division shall monitor the expenses and if the Division determines that the authorized limit may be exceeded, or that insufficient funds are available, the Division shall take the following actions:

(a) The Division shall continue to accept claims and date stamp them in the order the claims are received. The Division shall then suspend further processing of the claim;

(b) The Division shall notify each claimant that the claim has been suspended and the reason for the action;

(c) The Division shall maintain a file of suspended claims and await further legislative direction regarding the disposition of the claims.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.805 — ORS 414.815
Renumbered from 461-012-0150, DMAP 9-2011, f. 6-6-11, cert. ef. 7-1-11
AFS 10-2002, f. & cert. ef. 7-1-02
AFS 18-1995, f. & cert. ef. 8-1-95
AFS 24-1993, f. 10-27-93, cert. ef. 11-1-93
AFS 6-1992, f. & cert. ef. 3-9-92
AFS 1-1992, f. 1-14-92, cert. ef. 2-1-92

Division 165 OREGON MEDICAID ELECTRONIC HEALTH RECORD (EHR) INCENTIVE PROGRAM

Or. Admin. R. 410-165-0000 Basis and Purpose

(1) These rules (OAR chapter 410, division 165) govern the Oregon Health Authority (Authority), Health Systems Division (Division), Medicaid Electronic Health Record (EHR) Incentive Program. The Medicaid EHR Incentive Program provides incentive payments consistent with federal law concerning such payments to eligible providers participating in the Medicaid program who adopt, implement, upgrade, or successfully demonstrate meaningful use of certified EHR technology and who are qualified by the program.

(2) The Medicaid EHR Incentive Program is implemented pursuant to:

(a) The American Reinvestment and Recovery Act of 2009, Pub. L. No. 111-5, section 4201;

(b) The Centers for Medicare and Medicaid Services (CMS) federal regulation 42 CFR Part 495 (2010, 2012, 2014, and 2015) pursuant to the Social Security Act sections 1903(a)(3)(F) and 1903(t);

(d) The Authority’s Provider Rules, OAR chapter 943, division 120.

(3) The following retroactive effective dates apply to these rules:

(a) For all sections in these rules that refer to pediatric optometrists, the effective date is July 1, 2016;

(b) For rule 410-165-0080 that refers to:

(A) CMS federal regulation 42 CFR Part 495 (2016), the effective date is January 1, 2017;

(B) CMS federal regulation 42 CFR Part 495 (2017), the effective date is October 1, 2017;

(C) CMS federal regulation 42 CFR Part 495 (2018), in the FY 2019 Hospital Inpatient PPS Final Rule, sections 495.4, 495.24, 495.40, and 495.100, the effective date is October 1, 2018;

(D) CMS federal regulation 42 CFR Part 495 (2018) in the CY 2019 Medicare Physician Fee Schedule Final Rule, sections 495.4 and 495.24, the effective date is January 1, 2019.

(d) For eligible hospitals, except for sections and references in these rules applicable under section (3)(a) or (b) above, the effective date is October 1, 2013, which is also the start date for program year 2014;

(e) For eligible professionals, except for sections and references in these rules applicable under section (3)(a) or (b) above, the effective date is January 1, 2014, which is also the start date for program year 2014;

(f) For rule 410-165-0060 that refers to the grace period for program year 2017, the effective date is February 5, 2018.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
DMAP 4-2019, amend filed 03/08/2019, effective 03/08/2019
DMAP 13-2018, amend filed 03/08/2018, effective 04/01/2018
DMAP 46-2017, temporary amend filed 11/02/2017, effective 11/02/2017 through 04/30/2018
DMAP 18-2017, f. 5-31-17, cert. ef. 6-2-17
DMAP 3-2017(Temp), f. & cert. ef. 2-2-17 thru 7-31-17
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 20-2015, f. & cert. ef. 4-8-15
DMAP 2-2015(Temp), f. 1-30-15, cert. ef. 2-3-15 thru 8-1-15
DMAP 56-2013, f. & cert. ef. 10-22-13
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

Or. Admin. R. 410-165-0020 Definitions

The following definitions apply to OAR 410-165-0010 through 410-165-0140:

(1) “Acceptance Documents” means written evidence supplied by a provider demonstrating that the provider met Medicaid EHR Incentive Program eligibility criteria or participation requirements according to standards specified by the Division.

(2) “Acute Care Hospital” means a healthcare facility including, but not limited to, a critical access hospital with a Centers for Medicare and Medicaid Services’ (CMS) certification number (CCN) that ends in 0001-0879 or 1300-1399 and where the average length of patient stay is 25 days or fewer.

(3) “Adopt, Implement, or Upgrade” means:

(a) Acquire, purchase, or secure access to certified EHR technology capable of meeting meaningful use requirements;

(b) Install or commence utilization of certified EHR technology capable of meeting meaningful use requirements; or

(c) Expand the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training or upgrade from existing EHR technology to certified EHR technology.

(4) “Attestation” means a statement that:

(a) Is made by an eligible provider or preparer during the application process;

(b) Represents that the eligible provider met the thresholds and requirements of the Medicaid EHR Incentive Program; and

(5) “Certified EHR Technology” has the meaning given that term in 42 CFR 495.302 (2010, 2012, and 2014), 42 CFR 495.4 (2010, 2012, and 2015), 42 CFR 495.6 (2014), 42 CFR 495.20 (2015), and 45 CFR 170.102 (2010, 2011, 2012, 2014, and 2015).

(6) “Children’s Hospital” means a separately certified hospital, either freestanding or a hospital within a hospital that predominantly treats individuals under 21 years of age and that:

(a) Has a CCN that ends in 3300–3399; or

(b) Does not have a CCN but has been provided an alternative number by CMS for purposes of enrollment in the Medicaid EHR Incentive Program as a children’s hospital.

(7) “Dentist” has the meaning given that term in OAR 410-120-0000 and 42 CFR 440.100.

(8) “Eligible Hospital” means an acute care hospital with at least 10 percent Medicaid patient volume or a children’s hospital.

(9) “Eligible Professional” means a professional who:

(a) Is a physician, dentist, nurse practitioner, nurse-midwife nurse practitioner, pediatric optometrist, naturopathic physician, or physician associate practicing in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) that is so led by a physician associate;

(b) Meets patient volume requirements described in OAR 410-165-0060; and

(10) “Eligible Provider” means an eligible hospital or eligible professional.

(11) “Encounter” means:

(a) For an eligible hospital:

(A) Services rendered to an individual for inpatient discharge; or

(B) Services rendered to an individual in an emergency department on any one day.

(b) For an eligible professional, services rendered to an individual on any one day.

(12) “Enrolled Provider” means a hospital or health care practitioner who is actively registered with the Authority pursuant to OAR 943-120-0320.

(13) “Entity Promoting the Adoption of Certified EHR Technology” means an entity designated by the Authority that promotes the adoption of certified EHR technology by enabling:

(a) Oversight of the business and operational and legal issues involved in the adoption and implementation of certified EHR technology; or

(b) The exchange and use of electronic clinical and administrative data between participating providers in a secure manner including, but not limited to, maintaining the physical and organizational relationship integral to the adoption of certified EHR technology by eligible providers.

(14) “Federal Fiscal Year (FFY)” means October 1 to September 30.

(15) “Federally Qualified Health Center (FQHC)” has the meaning given that term in OAR 410-120-0000.

(16) “Grace Period” means a period of time or specified date following the end of a program year when an eligible provider may submit an application to the Medicaid EHR Incentive Program for that program year.

(17) “Hospital-based Professional” means a professional who furnishes 90 percent or more of Medicaid-covered services in a hospital emergency room (place of service code 23) or inpatient hospital (place of service code 21) in the calendar year (CY) preceding the program year, but does not include a professional practicing predominantly at a FQHC or RHC.

(18) “Individuals Receiving Medicaid” means individuals served by an eligible provider where the services rendered would qualify under the Medicaid encounter definition.

(19) “Meaningful EHR User” means an eligible provider that meets the criteria set forth in OAR 410-165-0080.

(20) “Medicaid Encounter” means:

(a) For an eligible hospital applying for program year 2011 or 2012:

(A) Services rendered to an individual per inpatient discharge where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, or cost-sharing; or

(B) Services rendered in an emergency department on any one day where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, and cost-sharing.

(b) For an eligible hospital applying for program year 2013 or later, either:

(A) Services rendered to an individual per inpatient discharge where the individual was enrolled in Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) if part of a state’s Medicaid expansion (does not apply to Oregon’s as it is designated as a separate CHIP state) at the time the billable service was provided; or

(B) Services rendered in an emergency department on any one day where the individual was enrolled in Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) if part of a state’s Medicaid expansion (does not apply to Oregon’s as it is designated as a separate CHIP state) at the time the billable service was provided.

(A) Services rendered to an individual on any one day where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or

(B) Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, and cost-sharing.

(d) For an eligible professional applying for program year 2013 or later, services rendered to an individual on any one day where the individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) if part of a state’s Medicaid expansion (does not apply to Oregon’s as it is designated as a separate CHIP state) at the time the billable service was provided.

(21) “National Provider Identifier” has the meaning given that term in 45 CFR Part 160 and OAR 410-120-0000.

(22) “Naturopathic Physician” has the meaning given that term in OAR 410-120-0000 and ORS Chapter 685.

(23) “Needy Individual” means individuals served by an eligible professional where the services rendered qualify under the needy individual encounter definition.

(24) “Needy Individual Encounter” means:

(a) For an eligible professional applying for program year 2011 or 2012, services rendered to an individual on any one day where:

(A) Medicaid or CHIP or a Medicaid or CHIP demonstration project approved under the Social Security Act section 1115 paid for part or all of the service;

(B) Medicaid or CHIP or a Medicaid or CHIP demonstration project approved under the Social Security Act section 1115 paid all or part of the individual’s premiums, copayments, or cost-sharing;

(D) The services were paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay.

(b) For an eligible professional applying for program year 2013 or later, services rendered to an individual on any one day where:

(A) The services were rendered to an individual enrolled in a Medicaid program or a Medicaid demonstration project approved under the Social Security Act section 1115 or CHIP at the time the billable service was provided;

(B) The services were furnished at no cost and calculated consistently with 42 CFR 495.310(h) (2010); or

(25) “Nurse Practitioner” has the meaning given that term in OAR 410-120-0000 and 42 CFR 440.166.

(26) “Optometrist” has the meaning given that term in OAR 410-120-0000 and ORS chapter 683.

(27) “Panel” means a managed care panel, medical or health home program panel, or similar provider structure with capitation or case assignment that assigns patients to providers.

(28) “Patient Volume” means:

(a) For eligible hospitals, the proportion of Medicaid encounters to total encounters expressed as a percentage;

(b) For eligible professionals who do not meet the definition of “practices predominantly,” the proportion of Medicaid encounters to total encounters expressed as a percentage;

(c) For eligible professionals who meet the definition of “practices predominantly,” the proportion of needy individual encounters to total encounters expressed as a percentage.

(29) “Pediatric Optometrist” means an optometrist who predominantly treats individuals under the age of 21.

(30) “Pediatrician” means a physician who predominantly treats individuals under the age of 21.

(31) “Physician” has the meaning given that term in OAR 410-120-0000 and 42 CFR 440.50.

(32) “Physician Associate” has the meaning given that term in OAR 410-120-0000 and 42 CFR 440.60.

(33) “Practices Predominantly” means an eligibility criterion to permit use of needy individual patient volume. An eligible professional practices predominantly if:

(a) For program year 2011 or 2012, more than 50 percent of an eligible professional’s total patient encounters over a period of six months in the calendar year preceding the program year occur at an FQHC or RHC;

(b) For program year 2013 and later, more than 50 percent of an eligible professional’s total patient encounters occur at an FQHC or RHC:

(A) During a six-month period in the calendar year preceding the program year; or

(B) During a six-month period in the most recent 12 months prior to attestation.

(34) “Preparer” means an individual authorized by an eligible provider to act on behalf of the provider to complete an application for a Medicaid EHR incentive via an electronic media connection with the Authority.

(35) “Program” means the Medicaid EHR Incentive Program.

(36) “Program Year” means:

(a) The CY for an eligible professional;

(b) For an eligible hospital:

(A) The federal fiscal year for program years 2011 through 2014 and for program 2015 if the attestation date is before December 15, 2015;

(B) The CY for program year 2015 and later if the attestation date is on or after December 15, 2015.

(37) “Provider Web Portal” means the Authority’s website that provides a secure gateway for eligible providers or preparers to apply for the Program.

(38) “Qualify” means to meet the eligibility criteria and participation requirements to receive a payment for the program year. The Program makes the determination as to whether an eligible provider qualifies.

(39) “Rural Health Clinic (RHC)” means a clinic located in a rural and medically underserved community designated as an RHC by CMS. Payment by Medicare and Medicaid to an RHC is on a cost-related basis for outpatient physician and certain non-physician services.

(40) “So Led” means when an FQHC or RHC has a physician assistant who is:

(a) The primary provider in the clinic;

(b) A clinical or medical director at the clinical site of practice; or

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
DMAP 21-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 18-2017, f. 5-31-17, cert. ef. 6-2-17
DMAP 3-2017(Temp), f. & cert. ef. 2-2-17 thru 7-31-17
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 20-2015, f. & cert. ef. 4-8-15
DMAP 2-2015(Temp), f. 1-30-15, cert. ef. 2-3-15 thru 8-1-15
DMAP 56-2013, f. & cert. ef. 10-22-13
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

Or. Admin. R. 410-165-0040 Application

(1) An eligible provider shall apply to the program each program year that the eligible provider seeks an incentive payment. To apply, an eligible provider or preparer shall:

(a) Register with CMS;

(b) After registering with CMS, follow the steps as outlined on the website at https://www.oregon.gov/oha/HPA/OHIT-MEHRIP/pages/index.aspx to apply to the program within the grace period for each program year:

(A) For program years 2011 and 2012, the following applies:

(i) For a first-year application, the grace period is 60 days;

(ii) For all subsequent years, the grace period is 90 days.

(B) For program year 2013, the grace period is 90 days;

(i) For eligible hospitals, the grace period ends on January 31, 2015;

(ii) For eligible professionals, the grace period ends on May 31, 2015.

(D) For program year 2015, the following applies:

(i) For eligible providers who are attesting for adopt, implement, or upgrade defined in section (3), the grace period ends on March 31, 2016;

(ii) For eligible hospitals that are attesting for meaningful use through CMS for the Medicare EHR Incentive Program and for the Medicaid EHR Incentive Program, the grace period ends on March 31, 2016;

(iii) For eligible professionals who are attesting for meaningful use described in OAR 410-165-0080, the grace period ends on August 31, 2016;

(iv) For eligible hospitals that are children’s hospitals defined in OAR 410-165-0020 that are attesting for meaningful use described in OAR 410-165-0080 through the Medicaid EHR Program, the grace period ends on December 31, 2016.

(E) For program year 2016, the following applies:

(i) For eligible hospitals, the grace period ends on March 31, 2017;

(ii) For eligible professionals that are not naturopathic physicians, the grace period ends on May 31, 2017;

(iii) For naturopathic physicians, the grace period ends on July 31, 2017.

(F) For program year 2017, the following applies:

(i) For eligible hospitals, the grace period ends on March 31, 2018;

(ii) For eligible professionals, the grace period ends on May 31, 2018;

(G) For program year 2018, the grace period ends on April 30, 2019;

(H) For program years 2019 and 2020 the grace period is 90 days;

(I) For program year 2021, the grace period does not apply. Information regarding program year 2021 application deadlines shall be established by the program.

(A) The information submitted is true, accurate, and complete; and

(B) They understand that any falsification or concealment of a material fact may be prosecuted under federal and state laws.

(d) Maintain for a minimum of seven years from the date of completed application complete, accurate, and unaltered copies of all acceptance documents associated with all data transmissions and attestations. The information maintained shall include at a minimum documentation to support:

(A) The financial or legal obligation for the adoption, implementation, or upgrade of certified EHR technology including, but not limited to, the purchase agreement or contract;

(B) Demonstration of meaningful use for the year corresponding to the program year;

(D) The eligible hospital’s payment calculation data including, but not limited to, Medicare cost reports.

(2) An eligible provider shall submit the acceptance documents referred to in section (1)(d)(A) when the eligible provider is attesting for a payment for the adoption, implementation, or upgrade to certified EHR technology or when new certified EHR technology is acquired. If the eligible provider is an eligible hospital seeking its first-year payment, it shall submit the acceptance documents referred to in section (1)(d)(D).

(3) The Program reviews the completed application and the acceptance documents to determine if the eligible provider qualifies for an incentive payment:

(a) The Program shall verify the information in the application;

(b) The Program shall determine if the eligible provider’s information complies with the eligibility criteria and participation requirements;

(d) The Authority may reduce the incentive payment to pay off debt if an eligible provider or incentive payment recipient owes a debt under a collection mandate to the State of Oregon. The incentive payment is considered paid to the eligible provider even when part or all of the incentive may offset the debt. The Authority may not reduce the incentive payment amount for any other purpose unless permitted or required by federal or state law; and

(e) The Authority shall distribute 1099 forms to the tax identification number designated to receive the Medicaid EHR incentive payment.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
DMAP 4-2019, amend filed 03/08/2019, effective 03/08/2019
DMAP 18-2017, f. 5-31-17, cert. ef. 6-2-17
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 20-2015, f. & cert. ef. 4-8-15
DMAP 2-2015(Temp), f. 1-30-15, cert. ef. 2-3-15 thru 8-1-15
Reverted to DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

Or. Admin. R. 410-165-0060 Eligibility

(1) There are three categories of eligibility criteria:

(a) Eligible professionals;

(b) Eligible professionals practicing predominately in a FQHC or RHC; and

(2) To be eligible for a Medicaid EHR incentive payment for the program year, an eligible professional as listed in Table 165-0060-1 shall meet the program criteria each year:

(a) To be eligible for an incentive payment, an eligible professional shall at a minimum:

(A) Meet and follow the scope of practice regulations as applicable for each profession as defined in 42 CFR Part 440;

(B) Meet the following certified EHR technology and meaningful use requirements for the corresponding year of participation:

(i) First year of participation:

(I) Adopt, implement, or upgrade certified EHR technology; or

(II) Meet the definition of a Meaningful EHR user described in OAR 410-165-0020.

(ii) Subsequent years of participation, meet the definition of a Meaningful EHR user described in OAR 410-165-0020.

(C) Either not be a hospital-based professional or for program year 2013 or later meet the requirements that allow a reversal of a hospital-based determination. To be considered non-hospital-based in future program years after an initial reversal determination, the professional shall attest in each subsequent program year that the professional continues to meet the requirements. To meet the requirements, the professional shall do all of the following:

(i) Fund the acquisition, implementation, and maintenance of certified EHR technology, including supporting hardware and interfaces needed for meaningful use without reimbursement from an eligible hospital and use such certified EHR technology in the inpatient or emergency department of a hospital;

(ii) Provide documentation to the Program for review and approval for the program year and in accordance with OAR 410-165-0040;

(iii) Meet all applicable requirements to receive an incentive payment; and

(iv) If attesting to meaningful use, demonstrate using all encounters at all locations equipped with certified EHR technology, including those in the inpatient and emergency departments of the hospital.

(D) Meet one of the following criteria:

(i) Have a minimum of 30 percent patient volume attributable to individuals receiving Medicaid; or

(ii) Be a pediatrician who has a minimum of 20 percent patient volume attributable to individuals receiving Medicaid.

(b) An eligible professional shall calculate patient volume as listed in Table 165-0060-2 by using the patient volume calculation method either of patient encounter or of patient panel. The patient panel volume calculation method may be used only when all of the following apply:

(A) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and

(B) There is an auditable data source to support the patient panel data.

(c) An eligible professional shall calculate patient volume as listed in Table 165-0060-2 by using either the patient volume of the eligible professional or the patient volume of the group. The patient volume of the group may be used only when all of the following apply:

(A) The group’s patient volume is appropriate as a patient volume methodology calculation for the eligible professional;

(B) There is an auditable data source to support the group’s patient volume determination;

(D) The group uses the entire practice or clinic’s patient volume and does not limit patient volume in any way; and

(E) If an eligible professional works inside and outside of the group, then the patient volume calculation includes only those encounters associated with the group and not the eligible professional’s outside encounters.

(d) An eligible professional’s patient volume must be calculated using one of the following methods:

(A) The patient encounter calculation method based on the patient volume of the eligible professional requires that:

(i) For program year 2011 or 2012, the eligible professional shall divide the total Medicaid encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period in the preceding calendar year; or

(ii) For program year 2013 and later, the eligible professional shall divide the total Medicaid encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period either in the preceding calendar year or in the twelve-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.

(B) The patient encounter calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012, the eligible professional shall divide the group’s total Medicaid encounters by the group’s total patient encounters in any representative, continuous 90-day period in the preceding calendar year;

(ii) For program year 2013 and later, the eligible professional shall divide the group’s total Medicaid encounters by the group’s total patient encounters in any representative, continuous 90-day period either in the preceding calendar year or in the twelve-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.

(i) For program year 2011 or 2012, the eligible professional shall:

(I) Add the total Medicaid patients assigned to the eligible professional’s panel in any representative, 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the eligible professional’s unduplicated Medicaid encounters rendered in the same 90-day period; and

(II) Divide the result calculated above in section (1)(d)(C)(i)(I) by the sum of the total patients assigned to the eligible professional’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period.

(ii) For program year 2013 and later, the eligible professional shall:

(I) Add the total Medicaid patients assigned to the eligible professional’s panel in any representative, 90-day period in either the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the eligible professional’s unduplicated Medicaid encounters rendered in the same 90-day period; and

(II) Divide the result calculated above in section (2)(d)(C)(ii)(I) by the sum of the total patients assigned to the eligible professional’s panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and

(III) Not use the same 90-day timeframe to calculate patient volume in different program years.

(D) The patient panel calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012, the eligible professional shall:

(I) Add the total Medicaid patients assigned to the group’s panel in any representative, 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the group’s unduplicated Medicaid encounters in the same 90-day period; and

(II) Divide the result calculated above in section (1)(d)(D)(i)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period.

(ii) For program year 2013 and later, the eligible professional shall:

(I) Add the total Medicaid patients assigned to the group’s panel in any representative, 90-day period in either the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the group’s unduplicated Medicaid encounters that same 90-day period;

(II) Divide the result calculated above in section (1)(d)(D)(ii)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and

(III) Not use the same 90-day timeframe to calculate patient volume in different program years.

(3) To be eligible for a Medicaid EHR incentive payment for the program year, an eligible professional practicing predominantly in an FQHC or an RHC, as listed in Table 165-0060-1, must meet the Program eligibility criteria each year by meeting either section (2) of this rule or by meeting the following FQHC and RHC specific criteria:

(a) At a minimum, the eligible professional shall:

(A) Meet and follow the scope of practice regulations as applicable for each professional as prescribed by 42 CFR Part 440;

(B) Meet the following certified EHR technology and meaningful use requirements for the corresponding year of participation:

(i) First year of participation:

(I) Adopt, implement, or upgrade certified EHR technology; or

(II) Meet the definition of a meaningful EHR user described in OAR 410-165-0020.

(ii) Subsequent years of participation, meet the definition of a meaningful EHR user described in OAR 410-165-0020.

(b) An eligible professional shall calculate patient volume as listed in Table 165-0060-3 by using the patient volume calculation method either of patient encounter or of patient panel. The patient panel volume calculation method may be used only when all of the following apply:

(A) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and

(B) There is an auditable data source to support the patient panel data.

(c) An eligible professional must calculate patient volume as listed in Table 165-0060-3 by using either the patient volume of the eligible professional or the patient volume of the group. The group’s patient volume may be used only when all of the following apply:

(A) The group’s patient volume is appropriate as a patient volume methodology calculation for the eligible professional;

(B) There is an auditable data source to support the group’s patient volume determination;

(D) The group uses the entire practice or clinic’s patient volume and does not limit patient volume in any way; and

(E) If an eligible professional works inside and outside of the group, the patient volume calculation includes only those encounters associated with the group and not the outside encounters.

(d) An eligible professional’s needy individual patient volume shall be calculated using one of the following methods:

(A) The patient encounter calculation method based on the eligible professional’s patient volume:

(i) For program year 2011 or 2012, the eligible professional shall divide the total needy individual encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period in the preceding calendar year;

(ii) For program year 2013 and later, the eligible professional shall divide the total needy individual encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period either in the preceding calendar year or in the12-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.

(B) The patient encounter calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012, the eligible professional shall divide the group’s total needy individual encounters by the group’s total patient encounters in any representative, continuous 90-day period in the preceding calendar year;

(ii) For program year 2013 and later, divide the group’s total needy individual encounters by the group’s total patient encounters in any representative, continuous 90-day period either in the preceding calendar year or in the 12-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.

(i) For program year 2011 or 2012, the eligible professional shall:

(I) Add the total needy individual patients assigned to the eligible professional’s panel in any representative, 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the eligible professional’s unduplicated needy individual encounters rendered in the same 90-day period; and

(II) Divide the result calculated above in section (2)(d)(C)(i)(I) by the sum of the total patients assigned to the eligible professional’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period.

(ii) For program year 2013 and later, the eligible professional shall:

(I) Add the total needy individual patients assigned to the eligible professional’s panel in any representative, 90-day period either in the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the eligible professional’s unduplicated needy individual encounters rendered the same 90-day period;

(III) Not use the same 90-day timeframe to calculate patient volume in different program years.

(D) The patient panel calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012, the eligible professional shall:

(I) Add the total needy individual patients assigned to the group’s panel in any representative, 90-day period in the prior calendar year, provided at least one needy individual encounter took place with the patient in the preceding calendar year, to the group’s unduplicated Medicaid encounters in the same 90-day period; and

(II) Divide the result calculated above in section (2)(d)(D)(i)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period.

(ii) For program year 2013 and later, the eligible professional shall:

(I) Add the total needy individual patients assigned to the group’s panel in any representative, 90-day period either in the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one needy individual encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the group’s unduplicated Medicaid encounters that same 90-day period;

(II) Divide the result calculated above in section (2)(d)(D)(ii)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and

(III) Not use the same 90-day timeframe to calculate patient volume in different program years.

(4) To be eligible for a Medicaid EHR incentive payment for the program year, an eligible hospital shall meet the Program criteria each year:

(a) To be eligible for an incentive payment, an eligible hospital shall meet the certified EHR technology and meaningful use requirements for the corresponding year of participation:

(A) First year of participation:

(i) Adopt, implement, or upgrade certified EHR technology;

(ii) Eligible hospitals that are children’s hospitals shall meet the definition of a meaningful EHR user; or

(iii) Eligible hospitals that participate in both the Medicare and Medicaid EHR Incentive Programs shall demonstrate meaningful use under the Medicare EHR Incentive Program to CMS and be deemed a meaningful EHR user for the program year.

(B) Subsequent years of participation:

(i) Eligible hospitals that participate in both the Medicare and Medicaid EHR Incentive Programs shall demonstrate meaningful use under the Medicare EHR Incentive Program to CMS and be deemed a meaningful EHR user for the program year; or

(ii) Eligible hospitals that are children’s hospitals shall meet the definition of a meaningful EHR user;

(b) If an eligible hospital is an acute care hospital, it shall calculate patient volume by dividing the total eligible hospital Medicaid encounters by the total encounters in any representative, continuous 90-day period:

(A) For program year 2011 and 2012, in the preceding federal fiscal year;

(B) For program year 2013 and later, either in the preceding federal fiscal year or in the 12-month timeframe preceding the attestation date. The eligible hospital may not use the same 90-day timeframe to calculate patient volume in different program years.

(5) Table 165-0060-1. [Table not included. See ED. NOTE.]

(6) Table 165-0060-2. [Table not included. See ED. NOTE.]

(7) Table 165-0060-3. [Table not included. See ED. NOTE.]

[ED. NOTE: Tables referenced are available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
DMAP 18-2017, f. 5-31-17, cert. ef. 6-2-17
DMAP 3-2017(Temp), f. & cert. ef. 2-2-17 thru 7-31-17
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 20-2015, f. & cert. ef. 4-8-15
DMAP 2-2015(Temp), f. 1-30-15, cert. ef. 2-3-15 thru 8-1-15
DMAP 56-2013, f. & cert. ef. 10-22-13
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 20-2011, f. 7-21-11, cert. ef. 7-22-11

Or. Admin. R. 410-165-0080 Meaningful Use

(1) An eligible provider shall demonstrate being a meaningful EHR user as prescribed by 42 CFR 495.4 (2010, 2012, 2015, 2016, 2017, and 2018), 42 CFR 495.6 (2010, 2012, and 2014), 42 CFR 495.8 (2010, 2012, and 2014), 42 CFR 495.20 (2015), 42 CFR 495.22 (2015, 2016, and 2017), 42 CFR 495.24 (2015, 2016, 2017, and 2018), and 42 CFR 495.40 (2015, 2016, 2017, and 2018):

(a) For eligible providers demonstrating meaningful use under the program in Stage 1 prior to December 15, 2015, to comply with 42 CFR 495.8, the State of Oregon requires the eligible provider to satisfy the objective “Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice;”

(b) For eligible hospitals:

(A) If CMS deems an eligible hospital to be a meaningful EHR user for the Medicare EHR Incentive Program for a program year, the eligible hospital is automatically deemed to be a meaningful EHR user for the program for the same program year;

(B) An eligible hospital deemed to be a meaningful EHR user by CMS for a program year does not have to meet the requirements specified in section (1)(a) for the program for the same program year.

(2) As prescribed by 42 CFR 495.4 (2010, 2012), the following meaningful use EHR reporting periods shall be used by eligible providers that are demonstrating meaningful use to the program for:

(a) Program years 2011, 2012, and 2013:

(A) Eligible professionals:

(i) For the first time, either:

(I) Any continuous 90-day period in the calendar year; or

(II) The calendar year.

(ii) For a subsequent time: the calendar year.

(B) Eligible hospitals:

(i) For the first time, either:

(I) Any continuous 90-day period in the federal fiscal year; or

(II) The federal fiscal year.

(ii) For a subsequent time, the federal fiscal year.

(b) Program year 2014:

(A) Eligible professionals, either:

(i) Any continuous 90-day period in calendar year 2014; or

(ii) Any of the following 3-month periods:

(I) January 1, 2014 through March 31, 2014;

(II) April 1, 2014 through June 30, 2014;

(III) July 1, 2014 through September 30, 2014; or

(IV) October 1, 2014 through December 31, 2014.

(B) Eligible hospitals, either:

(i) Any continuous 90-day period in federal fiscal year 2014; or

(ii) Any of the following 3-month periods:

(I) October 1, 2013 through December 31, 2013;

(II) January 1, 2014 through March 31, 2014;

(III) April 1, 2014 through June 30, 2014; or

(IV) July 1, 2014 through September 30, 2014.

(3) As prescribed by 42 CFR 495.4 (2015, 2016), the following meaningful use EHR reporting periods shall be used by eligible providers that are demonstrating meaningful use to the program for:

(a) Program year 2015, prior to December 15, 2015:

(A) Eligible professionals attesting for the first year, either:

(i) Any continuous 90-day period in the calendar year; or

(ii) The calendar year.

(B) Eligible professionals attesting for a subsequent year, the calendar year;

(i) Any continuous 90-day period in the federal fiscal year; or

(ii) The federal fiscal year.

(D) Eligible hospitals attesting for a subsequent year, the federal fiscal year.

(b) Program year 2015, on or after December 15, 2015, any continuous 90-day period in the calendar year;

(A) The first year, either:

(i) Any continuous 90-day period in the calendar year; or

(ii) The calendar year.

(B) A subsequent year, the calendar year.

(d) Program year 2016 after January 1, 2017:

(A) Any continuous 90-day period in the calendar year; or

(B) The calendar year.

(4) As prescribed by 42 CFR 495.4 (2017, 2018), the following meaningful use EHR reporting periods shall be used by eligible providers that are demonstrating meaningful use to the program for:

(a) Program year 2017 before October 1, 2017:

(A) The first year, either:

(i) Any continuous 90-day period in the calendar year; or

(ii) The calendar year.

(B) A subsequent year:

(i) Any continuous 90-day period in the calendar year; or

(ii) The calendar year for meaningful use objectives; and

(iii) A calendar year for the Clinical Quality Measures.

(b) Program year 2017 on or after October 1, 2017:

(A) Any continuous 90-day period in the calendar year; or

(B) The calendar year.

(A) The first year, either:

(i) Any continuous 90-day period in the calendar year; or

(ii) The calendar year.

(B) A subsequent year:

(i) Any continuous 90-day period in the calendar year; or

(ii) The calendar year for meaningful use objectives; and

(iii) A calendar year for the Clinical Quality Measures.

(d) Program year 2021: Any continuous 90-day period in the calendar year that ends before the application deadline specified in OAR 410-165-0040(1)(b)(I).

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & ORS 414.033
DMAP 4-2019, amend filed 03/08/2019, effective 03/08/2019
DMAP 13-2018, amend filed 03/08/2018, effective 04/01/2018
DMAP 46-2017, temporary amend filed 11/02/2017, effective 11/02/2017 through 04/30/2018
DMAP 18-2017, f. 5-31-17, cert. ef. 6-2-17
DMAP 3-2017(Temp), f. & cert. ef. 2-2-17 thru 7-31-17
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 20-2015, f. & cert. ef. 4-8-15
DMAP 2-2015(Temp), f. 1-30-15, cert. ef. 2-3-15 thru 8-1-15
DMAP 56-2013, f. & cert. ef. 10-22-13
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

Or. Admin. R. 410-165-0100 Participation and Incentive Payments

(1) To qualify for an incentive payment, an eligible provider shall meet the Program eligibility criteria and participation requirements for each year the eligible provider applies:

(a) An eligible provider shall meet the eligibility criteria for each program year of:

(A) Type of eligible provider;

(B) Patient volume minimum; and

(C) Certified EHR technology adoption, implementation, or upgrade requirements in the first year of participation and meaningful use requirements in subsequent years, or meaningful use requirements in all years of participation.

(b) An eligible provider must meet the participation requirements for each program year including:

(A) Be an enrolled Medicaid provider with the Division;

(B) Maintain current provider information with the Division;

(C) Possess an active professional license and comply with all licensing statutes and regulations within the state where the eligible provider practices;

(D) Have an active Provider Web Portal account;

(E) Ensure the designated payee is able to receive electronic funds transfer from the Authority; and

(F) Comply with all applicable Oregon Administrative Rules, including chapter 410, division 120, and chapter 943, division 120.

(A) The eligible professional’s employer with whom the eligible professional has a contractual arrangement allowing the employer to bill and receive payments for the eligible professional’s covered professional services;

(B) An entity with which the eligible professional has a contractual arrangement allowing the entity to bill and receive payments for the eligible professional’s covered professional services; or

(2) An eligible professional shall follow the Program participation conditions and requirements. The eligible professional shall:

(a) Receive an incentive payment from only one state for a program year;

(b) Only receive an incentive payment from either Medicare or Medicaid for a program year, but not both;

(c) Not receive more than the maximum incentive amount of $63,750 over a six-year period or the maximum incentive of $42,500 over a six-year period if the eligible professional qualifies as a pediatrician who meets the 20 percent patient volume minimum and less than the 30 percent patient volume;

(d) Participate in the Program:

(A) Starting as early as calendar year (CY) 2011, but no later than CY 2016;

(B) Ending no later than CY 2021;

(D) On a consecutive or non-consecutive annual basis.

(e) Be allowed to switch between the Medicare and Medicaid Programs only one time after receiving at least one incentive payment and only for a program year before 2015.

(3) The Authority shall disburse payments to the eligible professional following verification of eligibility for the program year:

(a) An eligible professional is paid an incentive amount for the corresponding program year for each year of qualified participation in the Program;

(b) The payment structure is as follows for:

(A) An eligible professional qualifying with 30 percent minimum patient volume:

(i) The first payment incentive amount is $21,250; and

(ii) The second, third, fourth, fifth, or sixth payment incentive amount is $8,500; or

(B) An eligible pediatrician qualifying with 20 percent but less than 30 percent minimum patient volume:

(i) The first payment incentive amount is $14,167; and

(ii) The second, third, fourth, or fifth payment incentive amount is $5,667;

(iii) The sixth payment incentive amount is $5,665.

(4) An eligible hospital shall follow the Medicaid EHR Incentive Program participation conditions including requirements that the eligible hospital:

(a) Receives a Medicaid EHR incentive payment from only one state for a program year;

(b) May participate in both the Medicare and Medicaid EHR Incentive Programs only if the eligible hospital meets all eligibility criteria for the program year for both programs;

(A) Starting as early as program year 2011 but no later than program year 2016;

(B) Ending no later than program year 2021;

(D) On a consecutive or non-consecutive annual basis for program years prior to program year 2016; and

(E) On a consecutive annual basis for program years starting in program year 2016.

(d) A multi-site hospital with one CMS CCN is considered one hospital for purposes of calculating payment.

(5) The Authority shall disburse payments to the eligible hospital following verification of eligibility for the program year. An eligible hospital is paid the aggregate incentive amount over three years of qualified participation in the Program:

(a) The payment structure as listed in Table 165-0100-1 is as follows:

(A) The first payment incentive amount is equal to 50 percent of the aggregate EHR amount;

(B) The second payment incentive amount is equal to 40 percent of the aggregate EHR amount; and

(b) The aggregate EHR amount is calculated as the product of the “overall EHR amount” times the “Medicaid Share” as listed in Table 165-0100-2. The aggregate EHR amount is calculated once for the first-year participation and then paid over three years according to the payment schedule:

(A) The overall EHR amount for an eligible hospital is based upon a theoretical four years of payment the hospital would receive and is the sum of the following calculation performed for each of such four years. For each year, the overall EHR amount is the product of the initial amount, the Medicare share, and the transition factor:

(i) The initial amount as listed in Table 165-0100-3 is equal to the sum of the base amount, which is set at $2,000,000 for each of the theoretical four years plus the discharge-related amount that is calculated for each of the theoretical four years:

(I) For initial amounts calculated in program years 2011 or 2012, the discharge-related amount is $200 per discharge for the 1,150th through the 23,000th discharge, based upon the total discharges for the eligible hospital (regardless of source of payment) from the hospital fiscal year that ends during the federal fiscal year (FFY) prior to the FFY year that serves as the first payment year. No discharge-related amount is added for discharges prior to the 1,150th or any discharges after the 23,000th;

(II) For initial amounts calculated in program year 2013 or later, the discharge-related amount is $200 per discharge for the 1,150th through the 23,000th discharge, based upon the total discharges for the eligible hospital (regardless of source of payment) from the hospital fiscal year that ends before the FFY that serves as the first payment year. No discharge-related amount is added for discharges prior to the 1,150th or any discharges after the 23,000th;

(III) For purposes of calculating the discharge-related amount for the last three of the theoretical four years of payment, discharges are assumed to increase each year by the hospital’s average annual rate of growth; negative rates of growth shall also be applied. Average annual rate of growth is calculated as the average of the annual rate of growth in total discharges for the most recent three years for which data are available per year.

(ii) The Medicare share that equals 1;

(iii) The transition factor that equals:

(I) 1 for the first of the theoretical four years;

(II) 0.75 for the second of the theoretical four years;

(III) 0.5 for the third of the theoretical four years; and

(IV) 0.25 for the fourth of the theoretical four years.

(B) The Medicaid share for an eligible hospital is equal to a fraction:

(i) The numerator for the FFY and with respect to the eligible hospital is the sum of:

(I) The estimated number of inpatient-bed-days that are attributable to Medicaid individuals; and

(II) The estimated number of inpatient-bed-days that are attributable to individuals who are enrolled in a managed or coordinated care organization, a pre-paid inpatient health plan, or a pre-paid ambulatory health plan administered under 42 CFR Part 438.

(ii) The denominator is the product of:

(I) The estimated total number of inpatient-bed-days with respect to the eligible hospital during such period; and

(II) The estimated total amount of the eligible hospital’s charges during such period, not including any charges that are attributable to charity care, divided by the estimated total amount of the hospital’s charges during such period.

(iii) In computing inpatient-bed-days for the Medicaid share, an eligible hospital may not include either of the following:

(I) Estimated inpatient-bed-days attributable to individuals that may be made under Medicare Part A; or

(II) Inpatient-bed-days attributable to individuals who are enrolled with a Medicare Advantage organization under Medicare Part C.

(iv) If an eligible hospital’s charity care data necessary to calculate the portion of the formula for the Medicaid share are not available, the eligible hospital’s data on uncompensated care may be used to determine an appropriate proxy for charity care but shall include a downward adjustment to eliminate bad debt from uncompensated care data if bad debt is not otherwise differentiated from uncompensated care. Auditable data sources shall be used; and

(v) If an eligible hospital’s data necessary to determine the inpatient bed-days attributable to Medicaid managed care patients are not available, that amount is deemed to equal 0. In the absence of an eligible hospital’s data necessary to compute the percentage of inpatient bed days that are not charity care as described under subparagraph (B)(ii)(II) in this section, that amount is deemed to be 1.

(6) The aggregate EHR amount is determined by the state from which the eligible hospital receives its first incentive payment. If a hospital receives incentive payments from other states in subsequent years, total incentive payments received over all payment years of the program can be no greater than the aggregate EHR amount calculated by the state from which the eligible hospital received its first incentive payment.

(7) Table 165-0100-1. [Table not included. See NOTE.]

(8) Table 165-0100-2. [Table not included. See NOTE.]

(9) Table 165-0100-3. [Table not included. See NOTE.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
DMAP 4-2019, amend filed 03/08/2019, effective 03/08/2019
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 20-2015, f. & cert. ef. 4-8-15
DMAP 2-2015(Temp), f. 1-30-15, cert. ef. 2-3-15 thru 8-1-15
DMAP 56-2013, f. & cert. ef. 10-22-13
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

Or. Admin. R. 410-165-0120 Appeals

(1) The appeals process for the Program is governed by 42 CFR 495.370 and the Authority’s Provider Appeals Rules in chapter 410, division 120.

(2) Pursuant to 42 CFR 495.312 and 42 CFR 495.370, the Authority may have CMS conduct the audits and handle any subsequent appeals of whether eligible hospitals are meaningful EHR users.

(3) A provider who applies for a Medicaid EHR incentive payment may appeal the Program’s decision. Appeals are governed by the Division’s Provider Appeal Rules OAR chapter 410, division 120. The provider’s appeal shall note the specific reason for the appeal, due to one or more of the following issues:

(a) An incentive payment;

(b) An incentive payment amount;

(d) The demonstration of adopting, implementing, or upgrading; or

(e) Meaningful use eligibility other than a meaningful use eligibility issue where CMS handles the appeal, as provided in section (2) of this rule.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 56-2013, f. & cert. ef. 10-22-13
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

Or. Admin. R. 410-165-0140 Oversight and Audits

(1) A provider who qualifies for a Medicaid Electronic Health Record (EHR) incentive payment under the Program is subject to audit or other post-payment review procedures pursuant to OAR 943-120-1505.

(2) The Authority and the Department of Human Services may recover overpayments from the person or entity who received an incentive payment from the Program.

(3) As authorized in 42 CFR 495.312, the Authority designates CMS to conduct audits on hospitals’ meaningful use attestations through program year 2014. For program year 2015 and later, the Authority and the Department of Human Services shall conduct these audits.

(4) The person or entity who received a Medicaid EHR incentive overpayment must repay the amount specified within 30 calendar days from the mailing date of written notification of the overpayment as prescribed by OAR 943-120-1505.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
DMAP 4-2019, amend filed 03/08/2019, effective 03/08/2019
DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16
DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16
DMAP 56-2013, f. & cert. ef. 10-22-13
DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13
DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

Division 170 BEHAVIOR REHABILITATION SERVICES PROGRAM GENERAL RULES

Or. Admin. R. 410-170-0000 Administration of the Behavior Rehabilitation Services (BRS) Program

(1) All BRS contractors shall, and ensure that their BRS providers, comply with the Medical Assistance programs rules in OAR Chapter 410, Division 120.

(2) All BRS contractors shall, and ensure that their BRS providers, comply with the BRS program general rules in OAR Chapter 410, Division 170.

(a) BRS contractors shall, and ensure that their BRS providers, comply with OAR Chapter 413, Division 095 to provide services or placement-related activities to BRS clients who receive prior authorization from the Department of Human Services;

(b) BRS contractors shall, and ensure that their BRS providers, comply with OAR Chapter 416, Division 335 to provide services or placement-related activities to BRS clients who receive prior authorization from the Oregon Youth Authority.

(3) The Oregon Health Authority may delegate authority to another agency or a unit of government to carry out some of its obligations under these rules.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0010 Purpose

The purpose of the Behavior Rehabilitation Services (BRS) Program is to remediate the BRS client’s debilitating psychosocial, emotional, and behavioral disorders by providing such services as behavioral intervention, counseling, and skills-training. Services are delivered in a way that integrates a gender-responsive, culturally-sensitive, trauma-informed, and age-appropriate or developmentally-appropriate approach. These rules describe the general program requirements for the BRS program, prior authorization process, services and placement-related activities, BRS contractor and BRS provider requirements, reimbursement rates, and compliance and oversight activities.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0020 Definitions

The following definitions apply to terms used in OAR Chapter 410, Division 170.

(1) “Accreditation” as defined in OAR 413-095-0000(2) means:

(a) An endorsement certifying that the BRS program meets all of the rigorous guidelines for service and quality established by any of the following entities:

(A) The Commission on Accreditation of Rehabilitation Facilities (CARF); or

(B) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO); or

(D) An independent, not for profit accrediting organization approved by the U.S. Department of Health and Human Services.

(b) A provisional endorsement issued by one of the entities described in section (a)(A)-(D) of this rule and conditionally approved by the Department for a period not to exceed 270 days from the date the provisional endorsement is issued.

(2) “Aftercare and Transition Plan (ATP)” means the written individualized service plan developed by the BRS contractor or BRS provider describing how the BRS client will successfully transition from its program to the community and identifying the aftercare services that must be provided to the BRS client following discharge.

(3) “Aftercare and Transition Plan — Stabilization (ATP–S)” means the aftercare and transition plan developed in a short-term stabilization program.

(4) “Aftercare Planning” means the process of developing a detailed description of the services to be delivered to the BRS client and the BRS client’s family, including fictive kin, through parent training during the aftercare period.

(5) “Age-Appropriate or Developmentally-Appropriate Activities” means activities or items that are generally accepted as suitable for children of the same chronological age or level of maturity or that are determined to be developmentally appropriate for a child, based on the development of cognitive, emotional, physical, and behavioral and social capacities that are typical for an age or age group. In the case of a specific child, age-appropriate or developmentally appropriate activities means activities or items that are suitable for the child based on the developmental stages attained by the child with respect to the cognitive, emotional, physical, behavioral and social capacities of the child.

(6) “Agency” means the state agency that has a contract with the BRS contractor to provide services and placement-related activities to the BRS client and provides prior authorization for the BRS client to receive services and activities pursuant to the BRS program general rules and, as applicable, agency-specific BRS program rules. The agency is one of the following state agencies: The Department of Human Services (Department), the Oregon Health Authority (Authority), or the Oregon Youth Authority (OYA).

(7) “Approved Proctor Foster Parent” means an individual who a BRS contractor, a BRS provider, or OYA approved to provide services or placement-related activities to the BRS client in the home of that individual. Approved proctor foster parents who provide services are considered direct care staff and shall meet those qualifications in OAR 410-170-0030. An OYA approved proctor foster parent is certified by OYA and a child-caring agency in accordance with the applicable provisions in OAR Chapter 416, Division 530 and Chapter 416, Division 550 and is employed by or has a contract or agreement with the child-caring agency to provide some services and placement-related activities to the BRS client in the proctor foster parent’s home.

(8) “Abbreviated AER” means the assessment and evaluation report developed when there is a transfer of the BRS client between BRS programs as described in OAR 410-170-0070(2)(d).

(9) “Assessment and Evaluation Report (AER)” means the written report detailing the findings of the assessment and evaluation of the BRS client conducted by a social service staff member as required in OAR 410-170-0070(2).

(10) “Assessment and Evaluation Report — Stabilization (AER–S)” means the assessment and evaluation report developed in a short-term stabilization program.

(11) “Behavior Rehabilitation Services (BRS) Program” means a program that provides services and placement-related activities to the BRS client to address their debilitating psychosocial, emotional, and behavioral disorders in a community placement utilizing either a residential care model or a proctor care model.

(12) “Billable Care Day” means each calendar day the BRS client is in the direct care of the BRS provider at 11:59 p.m. or meets the requirements in OAR 410-170-0110.

(13) “BRS Client” means the person who has prior authorization from an agency to receive services or placement-related activities through the BRS program.

(14) “BRS Contractor” means the entity contracted with an agency to be responsible for providing services and placement-related activities to the BRS client. The BRS contractor may also be the BRS provider if it provides direct services and placement-related activities to the BRS client.

(15) “BRS Provider” means a facility, institution, corporate entity, or other organization that provides direct services and placement-related activities to the BRS client.

(16) “BRS Type of Care” means the type of program model, services, placement-related activities, and staffing requirements and qualifications that are necessary to meet the medical and other needs of the BRS client.

(17) “Caseworker” means the individual who coordinates the services and placement-related activities for the BRS client with the BRS contractor and BRS provider.

(18) “Child or Children” means a person or persons under 21 years of age.

(19) “Child-Caring Agency” means a child-caring agency in ORS 418.205.

(20) “Children’s Health Insurance Program (CHIP)” means the federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered by the Authority.

(21) “Contract Administrator” means the employee or other individual designated in writing by the agency, by name or position description, to conduct the contract administration of a contract or class of contracts.

(22) “Crisis Intervention” means the BRS contractor or the BRS provider responding, either by phone or in person, to a crisis or urgent need of the BRS client or the BRS client’s aftercare resource for the purpose of providing aftercare services to the BRS client.

(23) “Critical Event” means a significant event including incidents described in OAR 413-215-0091(11)(b) occurring in the operation of the BRS contractor’s or BRS provider’s program that is considered likely to cause complaints, generate concerns, or come to the attention of the media, law enforcement agencies, first responders, Child Protective Services, or other regulatory agency.

(24) “Culture” means the sum of attitudes, customs, values, and beliefs that distinguishes one group of people from another.

(25) “Culturally-Sensitive Approach” means to enhance practices with culturally appropriate strategies through the knowledge and interpersonal skills that allow the BRS provider to understand, appreciate, engage, and work with individuals from their culture’s perspective.

(26) “Designated LPHA” means a licensed practitioner of the healing arts who has a contract with, is approved by, or is employed by the agency to make a determination on the medical appropriateness of the BRS program for the BRS client.

(27) “Department of Human Services (Department)” means the agency established in ORS Chapter 409, including such divisions, programs, and offices as may be established therein. For purposes of these rules, it refers to the Child Welfare Programs within the Department.

(28) “Direct Care Staff” means an individual who is employed by or who has a contract or an agreement with the BRS provider and is responsible for assisting social service staff in providing individual and group counseling, skills-training and therapeutic interventions, and monitoring and managing the BRS client’s behavior to provide a safe, structured living environment that is conducive to treatment.

(29) “Evidence-Based” as defined in OAR 413-095-0000(4) means an approach to medicine, education, and other disciplines that emphasizes the practical application of the findings of the best available current research.

(30) “Face to Face” means a personal interaction where both words can be heard and facial expressions can be seen in person or through telehealth services where there is a live streaming audio and video to the extent appropriate and in the BRS client’s best interest.

(31) “Fictive Kin” as defined in OAR 413-095-0000(5) has the same meaning as kith and means an individual who is not related to the BRS client by blood, adoption or marriage but has an emotionally significant relationship with the BRS client that has the characteristics of a family relationship.

(32) “Gender-Responsive Approach” means integrating those things that intentionally allow gender identity and development to affect and guide services and service delivery in order to create an environment (physical, social, emotional) that is responsive to the issues and needs of the BRS client being served.

(33) “Home Visit” means planned in-person contact between the BRS client and the BRS client’s immediate family, extended family, fictive kin, prior foster family, or other natural support persons.

(34) “Initial Service Plan (ISP)” means the initial written individualized services plan developed by the BRS contractor or BRS provider identifying the services that must be provided to the BRS client during the first 45 days in its BRS program or until the master service plan is written.

(35) “Licensed Practitioner of the Healing Arts (LPHA)” means a physician or other practitioner licensed in the State of Oregon who is authorized within the scope of the LPHA’s practice, as defined under state law, to diagnose and treat individuals with physical or mental disabilities or psychosocial, emotional, and behavioral disorders.

(36) “Master Service Plan (MSP)” means the written individualized services plan developed by the BRS contractor or BRS provider identifying the services that must be provided to the BRS client in its BRS program.

(37) “Master Service Plan — Stabilization (MSP–S)”means the master service plan developed in a short-term stabilization program.

(38) “Master Service Plan — Transition (MSP–T)” means the master service plan developed in an independent living program.

(39) “Medicaid” means the federal and state funded portion of the medical assistance programs established by Title XIX of the Social Security Act as amended and administered in Oregon by the Authority.

(40) “Monitoring” means in-person, phone or electronic contact by the BRS provider with the BRS client and those defined in 410-170-0070(1)(a)(B) to check on progress for the purpose of aftercare services, based on the needs identified in the BRS client’s Aftercare and Transition Plan.

(41) “Non-Qualified Residential Treatment Program” means BRS Contractors and BRS providers that provide services in a residential care model and that do not meet the requirements of a Qualified Residential Treatment Program.

(42) “Oregon Health Authority (Authority)” means the agency established in ORS Chapter 413 that administers the funds for Titles XIX and XXI of the Social Security Act. It is the single state agency for the administration of the medical assistance program under ORS chapter 414.

(43) “Oregon Youth Authority (OYA)” means the state department charged with the management and administration of youth correction facilities, state parole and probation services, and other functions related to state programs for youth offenders.

(44) “Physical Restraint” as defined in OAR 413-215-0076 means the act of restricting the BRS client’s voluntary movement as an emergency measure to manage and protect the client or others from injury when no alternate actions are sufficient to manage the client’s behavior. Physical restraint does not include temporarily holding a client to assist him or her or assure his or her safety, such as preventing a child from running onto a busy street.

(45) “Placement-Related Activities” means the BRS contractor’s and BRS provider’s activities related to the operation of the program and the care of the BRS client as set forth in the BRS program general rules, applicable agency-specific BRS program rules, the contract or agreement with the agency or the contractor, and applicable federal and state licensing and regulatory requirements. Placement-related activities may include but are not limited to providing the client with food, clothing, shelter, daily supervision; access to educational, cultural, and recreational activities; and case management. Room and board is not funded by Medicaid or CHIP.

(46) “Postvention” means the activities implemented by the BRS contractor and the BRS provider after a BRS client’s suspected suicide, including support for the bereaved family, friends, professionals, peers and those with geographic, social or social media ties to the deceased. In order to meet the needs of those bereaved by a suicide and to reduce the risk of contagion. Postvention includes the immediate postvention response implemented in the immediate days and weeks after a BRS client’s suspected suicide.

(47) “Proctor Care Model” means services and placement-related activities provided to the BRS client who resides in the home of an approved proctor foster parent.

(48) “Program Coordinator or Program Director” means an individual employed by or contracted with the BRS provider and responsible for supervising staff, providing overall direction to the BRS provider, planning and coordinating program activities and delivery of services and placement-related activities, and ensuring the safety and protection of the BRS client and the BRS provider’s staff.

(49) “Public Child-Caring Agency” means, for purposes of this rule, a program or institution operated by a governmental agency or unit other than the Department, OYA, or the Authority that provides care to the BRS client in a residential community setting.

(50) “Qualified residential treatment program (QRTP)”means a program that:

(a) Provides residential care and treatment to a BRS client who require specialized, evidence-based supports and services related to the effects of trauma or mental, emotional or behavioral health needs.

(b) Uses a trauma-informed treatment model that is designed to address the needs, including clinical needs as appropriate, of the BRS client.

(c) Ensures that the staff at the facility includes licensed or registered nurses licensed under ORS chapter 678 and other licensed clinical staff who:

(A) Provide care within their licensed scope of practice;

(B) Are on site according to the treatment model identified in subsection (b) of this section; and

(d) Facilitates the involvement of the BRS client’s family, including fictive kin, as defined in ORS 418.575, in the BRS client’s treatment program, to the extent appropriate and in the BRS client’s best interests.

(e) Facilitates outreach to the BRS client’s family, including fictive kin, as defined in ORS 418.575, documents how outreach is made and maintains contact information for any known biological relatives or fictive kin, as defined by the Department.

(f) Documents how the program integrates family, including fictive kin, into the BRS client’s treatment process, including after discharge, and how sibling connections are maintained.

(g) Provides discharge planning and family-based after-care support for at least six months following the BRS client’s discharge from the program.

(h) Is accredited as outlined in OAR 413-095-0000(2).

(51) “Residential Care Model” means that services and placement-related activities are provided to the BRS client in a residential community setting and not in the home of an approved proctor foster parent.

(52) “Respite Care” means a formally planned arrangement to relieve an approved, proctor foster parent’s responsibilities by an individual temporarily assuming responsibility for the care and supervision of the BRS client in the home of the respite provider or approved proctor foster parent. Respite care shall be 14 or fewer consecutive days.

(53) “Runaway Status” means the period of time when a BRS client has left or failed to return to their BRS placement without prior approval or authorization and has not been discharged from the BRS contractor’s program. This definition is for the purpose of 410-170-0110(3)(c).

(54) “Seclusion” means the involuntary confinement of a BRS client to an area or room from which the BRS client is physically prevented from leaving.

(55) “Service Coordination” means coordination activities identified in the BRS client’s Aftercare and Transition Plan, including: meeting with BRS client and BRS client’s family, including fictive kin, to develop and review goals; maintain or facilitate contact with service providers; and assist BRS client and BRS client’s family in obtaining services for the purpose of aftercare services.

(56) “Services” means the treatment provided to the BRS client in a BRS provider’s program, including but not limited to treatment planning, milieu therapy, individual and group counseling, skills-training, and parent training.

(57) “Social Service Staff” means an individual employed by or contracted with the BRS provider and is responsible for case management and the development of the service plans for the BRS client; individual, group, and family counseling; individual and group skills-training; assisting the direct care staff in providing appropriate treatment to the BRS client; coordinating services with other agencies; and documenting the BRS client’s treatment progress.

(58) “Suspected Suicide” means a death of a BRS client reported by a medical examiner or designee that is believed to have been caused by self-directed injurious behavior with an intent to die as a result of the behavior.

(59) “Total Daily Rate” means the total amount of the service payment and placement-related activities payment for a billable care day.

(60) “Transition Facilitator” means a social service staff employed by or contracted with the BRS provider and responsible for overseeing and monitoring the BRS client in the BRS contractor’s independent living program, either operated by itself or by its BRS provider, which includes but is not limited to assisting with developing the BRS client’s service plans and identifying support resources.

(61) “Transition Planning” means the process of preparing for a BRS client to successfully discharge from the BRS program into the community and is described in the ATP.

(62) “Transitional Visit” means an overnight visit by the BRS client to another paid placement for the purpose of facilitating the BRS client’s transition during the last 90 days of placement.

(63) “Trauma-Informed Approach” means an approach that recognizes and responds to the impact of traumatic stress on BRS clients and any other significant persons involved with the BRS client.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 49-2020, temporary amend filed 09/21/2020, effective 09/21/2020 through 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0030 BRS Contractor and BRS Provider Requirements

(1) The BRS contractor shall ensure that its BRS providers meet the following minimum requirements:

(a) Have the necessary current and valid licenses, approvals, or certifications required by federal or state law or regulations for the entity and its staff to operate a BRS program;

(b) Have a license to operate a child-caring agency;

(d) Comply with all applicable provisions of ORS 418.205 to 4138.327, OAR 413, Division 215, and any other federal and state laws and regulations governing child-caring agencies that apply to the type of BRS program being operated;

(e) Comply with the requirements in OAR 410-120-1380(1)(c)(J) for excluding individuals and entities from being subcontractors if they are found on the listed exclusion list; and

(f) Have a contract or agreement with an agency or, as applicable, a BRS contractor to provide services and placement-related activities to the BRS client.

(2) The BRS contractor shall, and ensure its BRS providers, comply with all applicable federal and state laws and regulations pertaining to the provision of Medicaid services under the Medicaid Act, Title XIX, 42 USC 1396 et seq. and the BRS program, including but not limited to all applicable provisions in OAR Chapter 410, Division 120.

(3) Confidentiality of BRS client information:

(a) BRS contractors shall, and ensure that their BRS providers, comply with the requirements for financial, clinical, and other records in OAR 410-120-1360, confidentiality requirements in OAR 410-120-1380, and all other applicable federal and state laws, rules, and regulations related to confidentiality and documentation requirements;

(b) The BRS contractor must not, and ensure its BRS providers do not, use or disclose any information concerning a BRS client for any purpose not directly connected with the administration of the BRS contractor’s or BRS provider’s program or as otherwise permitted by law, except with the written consent of the agency or if the agency is not the BRS client’s guardian, on the written consent of the person or persons authorized by law to consent to such use or disclosure;

(c) The BRS contractor shall, and ensure its BRS providers, comply with all applicable confidentiality requirements in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law 104-191, August 21, 1996) and its implementing regulations in 45 CFR 160 and 164 et. seq., and all applicable confidentiality requirements in state statutes and administrative rules, including but not limited to ORS 179.505 and OAR chapter 410, division 120;

(d) The BRS contractor shall, and ensure its BRS providers, secure appropriately all records and files related to BRS clients to prevent access by unauthorized persons or entities;

(e) Disclosure to the agency, Authority, or other governmental oversight or licensing entities:

(A) The BRS contractor shall, and ensure its BRS providers, provide access promptly to any information or written documentation in its possession related to the BRS client or its BRS program upon the request of the agency for any reason; and

(B) The BRS contractor shall, and ensure its BRS providers, provide access promptly to any information or written documentation in its possession related to the BRS client or its BRS program that is necessary for evaluating, overseeing, or auditing the BRS contractor’s program upon the request of the Authority or other governmental oversight or licensing entities.

(4) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, has a program coordinator, social service staff, and direct care staff who meet and maintain the following minimum qualifications:

(a) No less than 50 percent of the direct care staff for a BRS provider shall have a bachelor’s degree from an accredited college or university. A combination of formal education and experience with children may be substituted for a bachelor’s degree. Direct care staff shall be under the direction of a qualified social service staff member or a program coordinator;

(b) The program coordinator or program director shall have a bachelor’s degree from an accredited college or university, preferably with major study in psychology, sociology, social work, social sciences, or a closely allied field. The program coordinator or program director shall also have two years of experience in the supervision and management of a residential facility or a program using a proctor care model for the care and treatment of children;

(c) Social service staff shall have a master’s degree from an accredited college or university with major study in social work or a closely allied field and one year of experience in the care and treatment of children; or have a bachelor’s degree with major study in social work, psychology, sociology or a closely allied field, and two years of experience in the care and rehabilitation of children.

(d) A minimum of one identified staff person as described in sections (4)(a-c) who shall have necessary certifications through evidenced-based programs to provide leadership and training to maintain fidelity and trauma informed services;

(e) Direct care staff, social service staff, and the program coordinator who directly work with BRS clients shall:

(A) Receive a minimum of 28 hours of initial training prior to or within 30 days of employment or certification on the following topics: BRS services documentation, mandatory reporting of child abuse, program policies and expectations, gender- and cultural-specific services, behavior and crisis management, medication administration, discipline and restraint policies, and suicide prevention. Any direct care staff, social service staff, or program coordinator who has not yet completed this initial training prior to employment or certification shall be supervised by an individual who has completed this training when having direct contact with BRS clients; and

(B) Receive a minimum of 16 hours of training annually. Topics shall include skills-training that supports evidence-based or promising practices, behavior and crisis management, suicide prevention, and other subjects relevant to the responsibilities of providing services and placement-related activities to the BRS client; and

(5) Fitness Determination:

(a) The BRS contractor and BRS provider shall ensure its employees, volunteers, contractors, vendors, approved proctor foster parents, or other persons providing services or placement-related activities to BRS clients comply with all applicable criminal record and child abuse background checks and any fitness determination process required by federal or state law or regulation;

(b) The BRS contractor and the BRS provider shall ensure its employees, volunteers, contractors, vendors, approved proctor foster parents, or other persons providing services or placement-related activities to BRS clients who have not yet successfully completed the requirements in section (5)(a) of this rule are supervised by a person who has successfully met these requirements when having direct contact with BRS clients.

(c) Except in cases where more stringent legal requirements apply, the BRS contractor and BRS provider shall ensure its employees, volunteers, contractors, vendors, approved proctor foster parents, or other persons providing services or placement-related activities to BRS clients report to it any arrests or court convictions, any known allegation of child abuse or neglect, and any other circumstance that reasonably affects a fitness determination within one business day. The BRS contractor and BRS provider shall report this information to the agency on the same day it receives the information.

(6) Mandatory Reporting:

(a) The BRS contractor shall, and ensure its BRS providers, comply with the child abuse reporting laws in ORS 419B.005 through 419B.015 and the abuse reporting requirements for a child in care as described in ORS 418.257 through 418.258;

(b) The BRS contractor shall, and ensure its BRS providers, require its staff members to immediately report any abuse, as defined in ORS 419B.005(1), to the Department (whether or not they also report it to law enforcement under ORS 419B.015(1)(a)) when the staff member has reasonable cause to believe that a child with whom they have come into contact has suffered abuse or that a person with whom they come into contact has abused a child;

(c) The BRS contractor shall, and ensure its BRS providers, require its staff members to immediately report suspected abuse, as defined in ORS 418.257 through 418.258, of a BRS client or a child in care to the Department;

(d) The BRS contractor shall, and ensure its BRS providers, provide its staff members with an annual training and written materials on its staff members’ child abuse reporting obligations under sections (6)(b) and (6)(c) of this rule and information about the child abuse reporting hotline. Annual training and written materials are not needed if the BRS contractor or BRS provider does not have any employees, staff, or volunteers;

(e) For purposes of section (6) of this rule, staff members include the BRS contractor’s or BRS provider’s employees, volunteers, subcontractors, approved proctor foster parents, or other individuals providing services or placement-related activities to BRS clients.

(7) Communication:

(a) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, maintains a system for immediate and on-going communication among program staff regarding the whereabouts, status, and condition of the BRS clients in its program;

(b) The BRS contractor shall ensure and require its BRS provider to ensure that direct care staff and social service staff have access to a BRS client’s information to the extent it is relevant to providing the BRS client with services and placement-related activities;

(c) The BRS contractor shall provide or ensure that its BRS provider provides immediate verbal notification to the caseworker and the agency (if an additional contact person is designated) when there is a communication outage at the program and shall provide an alternative means by which the program may be contacted if possible.

(8) Staffing Requirements:

(a) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, meets and maintains appropriate staffing levels to ensure supervision of the BRS clients in its program 24 hours a day, seven days a week, including taking steps to ensure that a BRS client is supervised while temporarily outside of the program. The BRS provider may not leave a BRS client unsupervised, except in cases where there is a service plan for the BRS client to be out of the BRS provider’s direct supervision;

(b) For QRTP BRS contractors and QRTP BRS providers only: The requirements in section 410-170-0020(49)(c) of this rule may not be construed as requiring a Qualified Residential Treatment Program to acquire licensed nursing and licensed clinical staff solely through means of a direct employer to employee relationship.

(A) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, meets and maintains the following approved proctor foster parent to child ratios in its approved proctor foster parent homes:

(i) Shelter and Independent Living Program:

(I) A maximum of three BRS clients of any age shall be placed in the home of an approved proctor foster parent;

(II) A maximum of five children (including both BRS clients of any age and non-BRS clients under the age of 18) shall live in an approved proctor foster parent home with two parents;

(III) A maximum of four children (including both BRS clients of any age and non-BRS clients under the age of 18) shall live in an approved proctor foster parent home with one parent; and

(IV) No more than two children (including both BRS clients and non-BRS clients) under the age of three shall live in an approved proctor foster parent home.

(ii) Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, and Community Step Down:

(I) A maximum of two BRS clients shall be placed in the home of an approved proctor foster parent;

(II) A maximum of five children (including both BRS clients of any age and non-BRS clients under the age of 18) shall live in an approved proctor foster parent home with two parents;

(III) A maximum of four children (including both BRS clients of any age and non-BRS clients under the age of 18) shall live in an approved proctor foster parent home with one parent; and

(IV) No more than two children (including both BRS clients and non-BRS clients) under the age of three shall live in an approved proctor foster parent home;

(V) If the contractor provides proctor enhanced services subject to OAR 410-170-0090(3), the contractor shall provide supervision by professionally trained staff while any BRS client is in the facility. The contractor will ensure the BRS program meets and maintains a minimum daily ratio of 1 staff to 7 BRS clients.

(iii) Notwithstanding section (8)(b)(A)(i) and (ii) of this rule, a maximum of five BRS clients may be placed in the home of an approved proctor foster parent who is providing respite care.

(B) An OYA BRS contractor shall ensure its BRS program, either operated by itself or by its BRS provider, meets and maintains the approved proctor foster parent to child ratios described in OYA-specific BRS program rules for OYA approved proctor foster parent homes.

(d) For the residential care model, the BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, meets and maintains the following direct care staff to BRS client ratios for the BRS type of care it provides in its residential care BRS program:

(A) Shelter and Independent Living Program Staffing Ratio:

(i) Minimum Daily:

(l) Awake (16 hours); 1 staff: 7 BRS clients;

(ll) Asleep (8 hours); 1 staff: 10 BRS clients.

(ii) Weekly Average:

(l) Awake (16 hours); 1 staff: 5.5 BRS clients;

(ll) Asleep (8 hours); 1 staff: 10 BRS clients.

(B) Community Step-Down, Enhanced Structure Independent Living Program, Assessment and Evaluation, Basic Residential, and Rehabilitation Services Staffing Ratio:

(i) Minimum Daily:

(l) Awake (16 hours; 1 staff: 6 BRS clients;

(ll) Asleep (8 hours); 1 staff: 10 BRS clients.

(ii) Weekly Average:

(l) Awake (16 hours); 1 staff: 4.7 BRS clients;

(ll) Asleep (8 hours); 1 staff: 10 BRS clients.

(i) Minimum Daily:

(l) Awake (16 hours); 1 staff: 5 BRS clients;

(ll) Asleep (8 hours); 1 staff: 10 BRS clients.

(ii) Weekly Average:

(l) Awake (16 hours); 1 staff: 3.7 BRS clients;

(ll) Asleep (8 hours); 1 staff: 9 BRS clients.

(D) Intensive Behavioral Support Program Staffing Ratio:

(i) Minimum Daily:

(l) Awake (16 hours); 1 staff: 3.5 BRS clients;

(ll) Asleep (8 hours); 1 staff: 4.5 BRS clients.

(ii) Weekly Average:

(l) Awake (16 hours); 1 staff: 2.8 BRS clients;

(ll) Asleep (8 hours); 1 staff: 4.5 BRS clients.

(e) For purposes of calculating the number of direct care staff under section (8)(c) of this rule only, a social service staff member or program coordinator may be included if that staff member is specifically scheduled to and actually provides direct supervision to BRS clients onsite during the relevant time period;

(f) Under section (8)(c) of this rule only, in the event that no BRS clients are onsite at the program due to home visits, transitional visits, or other planned absences, the BRS contractor and BRS provider shall ensure that its program has the resources and procedures in place to serve the BRS client who may need to return to the program prior to the scheduled return date;

(g) In the event a BRS client is temporarily admitted to a hospital (other than to a psychiatric hospital) but is still enrolled in the BRS provider’s program, the BRS contractor and BRS provider shall ensure that its program works with the caseworker and the family when appropriate to develop a plan approved by the agency for supervision during the BRS client’s hospitalization;

(h) The BRS contractor may or allow its BRS provider to request prior written agency approval for its BRS program to deviate from the ratios described in sections (8)(c-d) of this rule or agency-specific BRS program rules. If the agency grants a waiver, this shall apply only to BRS program ratio requirements specified in these rules and agency-specific BRS program rules. The BRS contractor and BRS provider shall comply with any ratio requirements applicable under federal or state licensing requirements or approvals.

(9) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, does the following:

(a) Provides an environment suitable for the treatment of a BRS client that meets all applicable safety, health, and general environment standards required for a residential community setting if services are provided to the client in a residential care model, or in the home of an approved proctor foster parent certified by the BRS provider if services are provided to the client in a proctor care model;

(b) Provides separate bedrooms for persons under 18 and persons 18 years or older, except in cases where the child shares a bedroom with a person over 18 years old who is the child’s parent and caregiver or where there is written approval from the agency, and, if the BRS provider is a child-caring agency, the Children’s Care Licensing Program;

(c) Provides separate bedrooms for BRS clients who have inappropriate sexual behaviors identified in their service plan and BRS clients who do not have those behaviors identified in their service plan, unless there is written approval from the agency;

(d) Provides that BRS clients who have inappropriate sexual behaviors identified in their service plan occupy a bedroom either individually or in a group of three or more BRS clients who have inappropriate sexual behaviors identified in their service plan, unless there is written approval from the agency;

(e) Provides separate bedrooms for BRS clients and other members of the household, unless there is written approval from the agency;

(f) Provides separate bedrooms or dormitories for females and males. An exception to this requirement may be requested to the agency contract administrator and Children’s Care Licensing Program for BRS clients who identify outside of these gender binary categories, or for cases where the child shares a bedroom with a person of the opposite sex who is the child’s parent and caregiver;

(g) Provides physical separation of BRS clients served in its BRS program from individuals housed in a detention facility or youth correction facility;

(h) Provides that at least one door in each bedroom is unlocked at all times;

(i) Provides that at least one door in each dormitory is unlocked at all times, unless the BRS contractor or BRS provider receives prior written agency approval to lock all dormitory doors for eight hours at night; and

(j) Provides a means of egress for BRS clients to leave the residence.

(10) BRS providers and BRS contractors are not required to comply with section (9)(b) and (c) of this rule if they provide services or placement-related activities in a dormitory setting.

(11) BRS Program Policies and Procedures:

(a) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, has the following written policies and procedures that have been reviewed and approved by the agency:

(A) Admission criteria and standards to accept a BRS client into its program;

(B) Staff training policies and procedures, including child abuse reporting expectations under ORS 419B.005, 419B.010, and 419B.015;

(D) A behavior management system policy designed to consistently encourage appropriate behaviors by the BRS client in a non-punitive manner;

(E) A behavioral rehabilitation program model that uses evidence-based or promising practices whenever possible and the curriculum, policies, and procedures that implement that model;

(F) Policies regarding the BRS client’s and family’s rights, including but not limited to the search and seizure of the BRS client’s person, property, and mail; visitation and communication; and discharges initiated by the BRS client;

(G) A grievance policy describing the process through which the BRS client, and, if applicable, the BRS client’s parent, guardian, or legal custodian may present grievances to the BRS provider about its operation and a process to resolve issues;

(H) A suicide prevention policy and procedure that describes how the BRS provider shall respond in the event a BRS client exhibits self-injurious, self-harm, suicidal ideation, or suicide attempt. This policy shall describe warning signs of suicide; emergency protocol, and contacts; training requirements for staff, including suicide prevention training and suicide risk assessment tool training; procedures for determining implementation of additional supervision precautions and for determining removal of additional supervision precautions; suicide risk assessment procedures on the day of intake; documentation requirements for suicide ideation, self-harm, and special observation precautions to ensure immediate communication to all staff; a process for tracking suicide behavioral patterns; and a postvention plan with identified resources in the event of a suspected suicide;

(I) A seclusion and physical restraint policy that describes when such interventions may be used in compliance with applicable federal and state laws and regulations, including but not limited to requirements for licensed child-caring agencies and agency-specific BRS program rules. Physical restraint or seclusion shall be used only as a last resort, and may not be used for discipline, punishment, convenience of personnel, or as a substitute for activities, treatment, or training. The policy shall describe how staff are trained and monitored, who may perform such interventions, and how data on interventions are collected, maintained, and reported;

(J) A medication management policy that complies with applicable licensing requirements and agency-specific BRS program rules. At minimum, the policy shall describe:

(i) How and where medications are stored and dispensed; and

(ii) How the BRS provider shall notify the caseworker if the BRS client refuses prescribed medications for more than seven days or refuses a medication that is identified by any LPHA as requiring an immediate report for health care reasons.

(K) A quality improvement policy and procedures that monitor the operation of the BRS program to ensure compliance with all applicable laws and regulations, including but not limited to tracking service hours, monitoring the timeliness of reporting requirements, monitoring the quality of service delivery, and frequency of seclusion and physical restraints.

(L) For QRTP BRS Contractors only: A QRTP Compliance policy that describes how BRS contractor shall, and ensure that its BRS provider, implements and maintains QRTP requirements, and how BRS Contractor shall notify the Agency of its compliance status. This includes a description of how the BRS contractor and its BRS provider will ensure that a licensed or registered nurse, licensed under ORS chapter 678, and a licensed clinical professional are available 24 hours per day and seven days per week to provide care, within the licensed scope of practice of the nurse or professional, to a BRS client.

(b) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, reviews and updates its policies and procedures as listed in section (8)(a) of this rule biannually and has any updated policies and procedures reviewed and approved by the agency;

(d) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, complies with and maintains documentation of its compliance with all policies and procedures described in section (8)(a) of this rule and with any modifications to their policies and procedures that are required by the agency.

(12) Documentation Requirements:

(a) The BRS contractor and BRS provider shall:

(A) Comply with all documentation requirements in OAR 410-120-1360, BRS program general rules, and agency-specific BRS program rules;

(B) Use forms reviewed and approved by the agency to document the following if required: All service plans and updates; the assessment and evaluation report; the daily and weekly log for service hours; and the invoice form;

(C) Maintain current documentation of its staff’s compliance with applicable training, qualifications, and licensing requirements, which shall be readily available for on-site review by the caseworker, agency, and other appropriate licensing or oversight entity;

(D) Create, maintain, and update an individualized case file for each BRS client either in hard copy or electronically, including but not limited to signed consent for the BRS client to participate in the BRS program; documentation regarding home or other family, including fictive kin, visits and transitional visits; documentation of recreational, social, and cultural activities; documentation of legal custody or voluntary placement status; service documentation (service plans, weekly service description and hour records, and discrete service notes); face sheet with frequently referenced information; medical insurance information; education and vocation activities; school enrollment, attendance, progress, and discipline information; referral information; and any restriction or special permission for participation in activities, which shall be readily available for on-site review by the BRS provider’s direct care staff and social service staff, the caseworker, the agency, and the appropriate licensing or oversight entity;

(E) Ensure that all documentation about the BRS client is written in terms that are easily understood by all persons involved in service planning and delivery, including but not limited to the service plans, progress notes and reports, assessments, and incident reports; and

(F) Ensure that all documentation (paper or electronic) identifies any corrections made, including the original information, what was corrected or changed, the date of the correction, and who made the correction. White out, eraser tape, electronic deletions, or other means of eradicating information to make corrections on documentation may not be used.

(b) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, creates and maintains a record of all incidents, including but not limited to incidents described in OAR 413-215-0091(11)(b) and any use of seclusion or physical restraint on a form approved by the agency:

(A) Incident reports shall contain the following information:

(i) Name of the BRS client;

(ii) The date, location, type of incident, and duration of any seclusions or physical restraints employed in the context of the incident;

(iii) Name of staff involved in the incident, including the names of any witnesses;

(iv) Description of the incident, including precipitating factors, preventative efforts employed, and description of circumstances during the incident;

(v) Physical injuries to the BRS client or others resulting from the incident, including information regarding any follow-up medical care or treatment;

(vi) Documentation showing that any necessary reports were made to the appropriate agency, any other entity required by law to be notified, and, as applicable, the BRS client’s parent, guardian, or legal custodian;

(vii) Documentation indicating the date that a copy of the incident report was sent to the caseworker;

(viii) Actions or interventions taken by program staff;

(ix) Any follow-up recommendations for the BRS client or staff;

(x) Any follow-up or investigation conducted by the BRS contractor or BRS provider’s supervisory staff and administrative personnel, the Department, the Authority, OYA or other entities; and

(xi) The BRS contractor’s or BRS provider’s review of the incident.

(B) The BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, provides immediate verbal or electronic notification to the caseworker, the agency’s contract administrator, and, as applicable, the appropriate licensing entity of the following types of critical events: Incidents posing a risk to the status or custody of the BRS client and any other incidents that are of a nature serious enough to raise safety, programmatic, or other serious concerns. Immediate notification shall be followed up by the submission of a written incident report to the individuals or entities described in this section within one business day. Compliance with this notification requirement does not satisfy child abuse reporting requirements under ORS 419B.005 to 419B.015 and ORS 418.257 and 418.258;

(C) At the end of each month, the BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, sends copies of all incident reports for that month, not previously submitted under section (12)(b)(B) of this rule, to the BRS client’s caseworker and contract administrator.

(c) The BRS contractor and BRS provider shall provide prompt documentation to the agency upon request or by the deadline specified in a written request, whichever is sooner. The BRS contractor’s or BRS provider’s failure to provide the agency with the requested documentation by the agency’s deadline may result in the agency pursuing any one or a combination of the sanctions or remedies against the BRS contractor described in OAR 410-170-0120 or agency-specific BRS rules.

(13) The BRS contractor shall ensure that its program, either operated by itself or by its BRS provider, provides prior notification to the caseworker whenever the BRS client is sleeping outside of its program for any reason, excluding cases of emergency:

(a) Initial approval shall be completed at intake and shall include information from the caseworker documenting any special instructions such as:

(A) Conditions under which an overnight absence from the program would be approved;

(B) Home visit resources that are acceptable;

(D) Approved and non-approved contacts during absences, as applicable; and

(E) Approved and non-approved activities, as applicable.

(b) After initial approval by the caseworker, the BRS contractor shall ensure that its BRS program, either operated by itself or by its BRS provider, notifies the caseworker of each upcoming overnight visit at least two business days prior to the visit and provides the following information:

(A) Dates of visit;

(B) Type of visit or activity;

(D) Explanation of how any special conditions or requirements are addressed.

(c) The BRS contractor and BRS provider may not permit the BRS client to leave the state or country without prior written approval by the agency.

(14) BRS contractors shall, and ensure that their BRS providers, are not institutions for mental diseases, as defined in 42 CFR 435.1010, unless they are providing inpatient psychiatric services to BRS clients in compliance with the requirements in 42 CFR 441.151 and 42 CFR 440.160.

(15) The BRS contractor’s supervision of the BRS provider:

(a) The BRS contractor is responsible for monitoring and ensuring that its BRS providers comply with all applicable laws and regulations related to the BRS program. The Authority may pursue any sanctions, remedies, or recoveries as described in OAR 410-170-0120, OAR 410-120-1397, or OAR 410-120-1400 against the BRS contractor for failing to monitor and ensure its BRS providers comply with all applicable laws and regulations related to the BRS program;

(b) The BRS contractor is solely responsible for all obligations owed to its BRS provider under its subcontract or agreement.

(16) The BRS contractor’s supervision of the approved proctor foster parent:

(a) The BRS contractor shall, and ensure that its BRS provider, monitors and ensures that its approved proctor foster parents comply with all applicable laws and regulations related to the BRS program. The Authority may pursue any sanctions, remedies, or recoveries described in OAR 410-170-0120, OAR 410-120-1397, or OAR 410-120-1400 against the BRS contractor for failing to monitor and ensure its approved proctor foster parents are in compliance with all applicable laws and regulations related to the BRS program;

(b) The BRS contractor shall, and ensure that its BRS provider:

(A) Recruits, trains, reimburses, and supports the approved proctor foster parent in providing services or placement-related activities to the BRS client;

(B) Visits the approved proctor foster parent’s home a minimum of one time each month for the purposes of support that includes but is not limited to monitoring, training, and supervision;

(i) The BRS contractor shall, and ensure that its BRS provider, have staff available to provide the approved proctor foster parent with back-up services 24 hours per day, seven days a week, which includes on-call services, consultation, and direct crisis counseling. Approved proctor foster parents shall receive the contact details (names and phone numbers) of the program staff that are available to provide these back-up services;

(ii) The BRS contractor shall provide, or ensure that its BRS provider provides, the approved proctor foster parent with the opportunity to receive 48 hours per month of time away from approved proctor foster parent responsibilities. Daytime supervision and night-time monitoring equivalent to that provided by the approved proctor foster parent shall be arranged and provided to the BRS client during that time.

(c) The BRS contractor or, as applicable, the BRS provider is solely responsible for all obligations owed to the approved proctor foster parent under its subcontract or agreement.

(17) The BRS contractor shall, and ensure that its BRS provider, notifies the agency in writing when a current employee or newly hired employee is also an employee of the agency. The BRS contractor shall, and ensure that its BRS provider, submits the notification to the contract administrator and the agency’s contracts unit and shall include the name of the employee and their job description. The agency shall review the employment situation for any actual or potential conflicts of interest as identified under ORS chapter 244.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0040 Prior Authorization for the BRS Program; Hearing Rights

(1) The BRS program requires prior authorization from the agency in accordance with the Authority’s rules, the general BRS program rules, and applicable agency-specific BRS program rules. A referral by an LPHA or agency to the Authority for prior authorization of the BRS program is not a prior authorization.

(2) Prior Authorization Criteria for the BRS program:

(a) The Authority shall provide prior authorization for the BRS program to an individual who:

(A) Is enrolled in the Oregon Health Plan (OHP), is eligible for Oregon’s Medicaid or CHIP program, and is eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services, according to the procedures established by the Authority;

(B) Has a determination by a designated LPHA that the BRS program is medically appropriate to meet the individual’s medical needs;

(C) Is not receiving residential mental health or residential developmental disability services from another governmental unit or entity;

(D) Is a child; and

(E) Does not have a current prior authorization for the BRS program for the requested time period from OYA or the Department.

(b) OYA or the Department may provide prior authorization for the BRS program for an individual that meets the requirements in its agency-specific BRS program rules.

(3) To meet the requirement in section (2)(a)(B) of this rule, the designated LPHA shall determine that the BRS program is medically appropriate because the individual:

(a) Has a primary mental, emotional, or behavioral disorder or developmental disability that prevents the individual from functioning at a developmentally appropriate level in the individual’s home, school, or community;

(b) Demonstrates severe emotional, social, and behavioral problems, including but not limited to: Drug and alcohol abuse; anti-social behaviors requiring close supervision, intervention, and structure; sexual behavioral problems; or behavioral disturbances;

(c) Requires out-of-home behavioral rehabilitation treatment to restore or develop the individual’s appropriate functioning at a developmentally appropriate level in the individual’s home, school, or community;

(d) Is able to benefit from the BRS program at a developmentally-appropriate level;

(e) Does not have active suicidal, homicidal, or serious aggressive behaviors; and

(f) Does not have active psychosis or psychiatric instability.

(4) The Authority may also request that the designated LPHA determine the BRS type of care that is medically appropriate for the individual. The designated LPHA shall make that determination based on the following factors, including but not limited to the:

(a) Severity of the individual’s psychosocial, emotional, and behavior disorders;

(b) Intensity and type of services that would be appropriate to treat the individual;

(d) Least restrictive and intensive setting based on the individual’s treatment history, degree of impairment, current symptoms, and the extent of family, including fictive kin, and other supports; and

(e) Behavior management needs of the individual.

(5) The agency is not required to provide prior authorization or to make payment for services or placement-related activities under the following circumstances:

(a) The individual was not eligible for the BRS program at the time services or placement-related activities were provided;

(b) The documentation is not adequate to determine the type, medical appropriateness, or frequency and duration of services;

(c) The services or placement-related activities billed or provided are not consistent with the information submitted when the prior authorization was requested;

(d) The services or placement-related activities billed are not consistent with those provided;

(e) The services or placement-related activities were not provided within the timeframe specified on the notice of prior authorization;

(f) The BRS program is not covered under the individual’s medical assistance package;

(g) The services or placement-related activities were not authorized or provided in compliance with the BRS program general rules, agency-specific BRS program rules, or applicable Oregon Health Authority General Rules (OAR Chapter 410, Division120);

(h) The individual does not meet the prior authorization requirements as stated above;

(i) The BRS contractor or BRS provider was not eligible to receive reimbursement through the BRS program at the time the services or placement-related activities were provided; or

(j) The individual’s needs are better met through another system of care; the individual is eligible for services under that system of care; the individual is given notice of that eligibility; and the services necessary to support a successful transition to the alternate system of care are provided.

(6) Retroactive eligibility and authorization:

(a) In those instances when the BRS client is made retroactively eligible for the BRS program, the agency may grant prior authorization if:

(A) The BRS contractor or BRS provider received preliminary approval from the agency prior to admitting the BRS client into its program while the prior authorization process was pending; and

(B) The BRS client met all prior authorization criteria and eligibility requirements on the date that the services and placement-related activities were provided; and

(C) The BRS provider delivered the services and placement-related activities in accordance with all applicable BRS program general rules and agency-specific BRS program rules; and

(D) Prior authorization was retroactively approved by the agency within five business days from the date that the BRS client was admitted into the BRS provider’s program.

(b) Prior authorization after five business days from the date the BRS client was admitted into the BRS contractor’s or BRS provider’s program requires documentation that prior authorization could not have been obtained within those five business days.

(7) Prior authorization is valid for the time-period specified on the agency’s prior authorization notice but is not to exceed 12 months from the date on the notice, unless the BRS client is no longer eligible for a medical assistance program that covers the BRS program, in which case the authorization shall terminate on the date coverage ends.

(8) The BRS contractor and BRS provider is responsible for ensuring that there is a prior authorization from the agency for the BRS client in advance of providing the services or placement-related activities for the applicable time period unless section (6) of this rule applies.

(9) If an individual is denied prior authorization for the BRS program under section (2)(a) of this rule, OAR 413-095-0040(1)(a) or OAR 416-335-0040(1)(a), the individual is entitled to notice and contested hearing rights under OAR 410-120-1860 and 410-120-1865. The contested case hearing shall be held by the Authority.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0050 Program Referrals and Admission to BRS Provider

(1) After the BRS client receives prior authorization for the BRS program, the agency shall refer the BRS client for admission to one or more BRS contractors or BRS providers that provide the appropriate BRS type of care.

(2) The agency shall provide the BRS contractor or, as applicable, the BRS provider with the following documents in the BRS client’s referral packet:

(a) Information identifying the individual or entity with legal authority over the BRS client, which may be the BRS client’s parent, guardian, or legal custodian;

(b) Any prior evaluations, assessments, or other documents that provide background information about the BRS client or that support the need for the BRS client’s current level of services; and

(3) The BRS contractor or, as applicable, the BRS provider shall make admission decisions for the BRS client based on its agency-approved written admission criteria, unless provided with written authorization from the agency to accept a BRS client who does not meet its admission criteria.

(4) The BRS contractor or, as applicable, the BRS provider may not deny an eligible BRS client admission to its program if a vacancy exists within the program at the time of referral and the BRS client meets its agency-approved admission criteria, unless it receives written approval from the referring agency.

(5) The BRS contractor may not and shall ensure its BRS providers do not deny an eligible BRS client admission to its program for any of the following reasons:

(a) The presence or absence of family members, or fictive kin, to support the placement;

(b) The race, religion, sexual orientation, color, or national origin of the BRS client involved;

(d) The absence of an identified after-care resource.

(6) The BRS contractor shall, and ensure its BRS provider, notifies the caseworker of its admission decision within five business days of receiving the BRS client’s referral packet unless an earlier timeframe is required in agency-specific BRS rules. If the BRS provider denies admission to the BRS client, then it shall provide the caseworker with a written explanation.

(7) The BRS contractor shall, and ensure its BRS provider, maintains documentation (either electronically or in hard copy) of all its admission decisions for BRS clients referred by an agency or BRS contractor, which includes the following:

(a) The name of the BRS client referred;

(b) The date the referral was received;

(d) The date the referral was responded to in writing.

(8) Intake Procedures:

(a) On the day that the BRS client is physically admitted to the BRS contractor’s or BRS provider’s program, its staff shall provide the BRS client and, as applicable, the BRS client’s parent, guardian, or legal custodian with copies of the following policies:

(A) Behavior management system policy;

(B) Grievance policy;

(C) BRS client’s and family’s rights policies, including but not limited to visitation and communication policies and the policies regarding the search and seizure of the BRS client’s person, property, and mail;

(D) Discharge polices, including but not limited to a discharge initiated by the BRS client;

(E) Seclusion and physical restraint policies;

(F) Suicide prevention policy and procedures; and

(G) Medication management policy.

(b) The BRS contractor must ensure its program, either operated by itself or by its BRS provider, maintains signed documentation indicating that the BRS client and, as applicable, the BRS client’s parent, guardian, or legal custodian received and understood the information described in section (8)(a) of this rule;

(c) If any of the policies described in section (8)(a) of this rule are individualized for a BRS client and differ from the program’s standard documented practices, these variations shall be explained and documented and included in or attached to the BRS client’s service plan;

(d) If the BRS client’s parent, guardian, or legal custodian is unavailable at the time of admission, the BRS contractor shall ensure its program, either operated by itself or by its BRS provider, documents in the BRS client’s case file that it forwarded this information to the BRS client’s parent, guardian, or legal custodian by facsimile, mail, or electronic mail within 48 hours of the BRS client’s admission to the program.

(9) The agency is responsible for notifying the BRS contractor or BRS provider of any changes to the information described in section (2) of this rule. In addition, the agency shall provide the BRS contractor or BRS provider with the following information:

(a) Applicable written authorizations by the BRS client or the BRS client’s parent, guardian, or legal custodian consenting to the BRS client’s participation in the BRS program;

(b) If applicable, the prepaid health plan or coordinated care organization in which the BRS client is enrolled;

(d) If applicable, the BRS client’s school information, parental contact information, or similar types of information.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0060 Discharge from the BRS Contractor or BRS Provider

(1) Planned discharge initiated by the BRS contractor, BRS provider, or the agency:

(a) Initiated by the BRS contractor or BRS provider:

(A) The BRS contractor shall, and require that its BRS providers, notify the caseworker in writing as soon as reasonably practicable regarding its intent to initiate the planned discharge of the BRS client from its program;

(B) Following notification, the BRS contractor or BRS provider and caseworker shall meet to discuss the case. If a discharge date can be agreed upon, the BRS client shall be discharged on that date. If they cannot agree, the caseworker shall remove the BRS client from the program within 30 days from the original written notice to the caseworker, resulting in the BRS client’s planned discharge.

(b) Initiated by the agency:

(A) The BRS client’s caseworker shall notify the BRS contractor or BRS provider in writing as soon as reasonably practicable regarding the agency’s intent to initiate the planned discharge of the BRS client from its program;

(B) Following notification, the caseworker and the BRS contractor or BRS provider must meet to discuss the case. If a discharge date can be agreed upon, the BRS client must be discharged on that date. If they cannot agree, the caseworker may remove the BRS client from the program resulting in the BRS client’s planned discharge.

(2) Emergency Discharge:

(a) Initiated by the BRS contractor or BRS provider:

(A) The BRS contractor or BRS provider may request the immediate discharge of a BRS client from its program if, after contact with the agency staff, there is agreement that the BRS client is a clear and immediate danger to self or others. In such situations, the caseworker must consider the notification a priority and respond to the BRS contractor or BRS provider as soon as practicable but no later than one business day;

(B) The BRS contractor shall, and ensure its BRS providers, discuss the BRS client’s continuation in, temporary removal from, or discharge from the program.

(b) The agency may immediately remove the BRS client from the BRS contractor’s or BRS provider’s program for any reason, resulting in the BRS client’s emergency discharge;

(c) A parent or guardian with appropriate legal authority, as determined by the agency, may immediately remove the BRS client from the BRS contractor’s or BRS provider’s program, resulting in the BRS client’s emergency discharge.

(3) Discharge initiated by the BRS client:

(a) The BRS client may initiate discharge from the BRS provider by submitting a written request to the BRS contractor, BRS provider, or caseworker:

(A) If the request is submitted to the program, the BRS contractor shall, and ensure its BRS provider, submits immediate verbal or written notification to the caseworker and the agency’s designated contact and, if applicable, the BRS client’s parent, guardian, or legal custodian to allow for alternate placement arrangements;

(B) The caseworker or the agency’s designated contact shall make alternative placement arrangements within five business days from receiving the request from the BRS client or the notice from the BRS contractor or BRS provider, whichever is earlier.

(b) Section (3)(a) of this rule does not apply to clients less than 18 years old in a BRS placement that:

(A) Does not meet the definition of a “public institution” in 42 CFR 435.1010; or

(B) Meets the definitions of a “publicly operated community residence” or a “child-care institution” in 42 CFR 435.1010.

(c) Notwithstanding section (3)(a) of this rule, the child’s legal guardian may commit a child to a BRS placement without the child’s consent or over the child’s objection (i.e.,override the child’s decision to leave the BRS program) if the following conditions are met:

(A) The child is under the age of 18 and is not legally emancipated or married;

(B) The guardian has legal authority to make medical decisions for the child; and

(4) Discharge from a program does not impact a BRS client’s prior authorization for the BRS program generally. A BRS client may be referred to another BRS contractor or BRS provider or request re-referral to the same program if the prior authorization remains valid and the BRS client remains eligible for the BRS program.

(5) The agency may temporarily remove the BRS client for any reason without resulting in a discharge from the BRS contractor’s or BRS provider’s program.

(6) Storage of the BRS client’s personal property:

(a) The BRS contractor shall, and ensure its BRS providers, store property belonging to the BRS client in its program for up to 30 days in a secure location following discharge when the BRS client exits the program without the client’s property;

(b) The BRS contractor shall, and ensure its BRS providers, contact the BRS client’s caseworker as soon as possible to make arrangements for the property to be retrieved.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0070 BRS Service Planning

(1) Initial Service Plan (ISP):

(a) A BRS contractor that provides services and placement-related activities in a Shelter, Independent Living program, Enhanced Structure Independent Living program, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Basic Rehabilitation, Intensive Residential, Intensive Rehabilitation, or Intensive Behavioral Support program shall, and require that its BRS providers:

(A) Ensure that a social service staff member completes a written ISP within two business days of the BRS client’s admission to its program;

(B) Provide an opportunity for the following individuals to participate in developing the BRS client’s ISP, including but not limited to the BRS client, the BRS client’s family, fictive kin, social service staff, the BRS client’s caseworker, and any other significant individuals involved with the BRS client;

(C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the ISP;

(D) Obtain written approval of the ISP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and

(E) Provide the services identified in the ISP during the first 45 days in the BRS provider’s program or until the MSP is written.

(b) The BRS contractor shall, and require that its BRS provider types listed in section (1)(a) of this rule, ensure that the ISP is individualized, developmentally appropriate, based on a thorough assessment of the BRS client’s referral information, and include at minimum the following:

(A) A plan to address specific behaviors and needs identified in the referral information including the intervention to be used;

(B) A plan for any overnight home visits and transitional visits;

(D) The anticipated type of placement at discharge;

(E) Existing orders for medication and any prescribed treatments for medical conditions, mental health conditions, or substance abuse;

(F) Any type of behavior management system that is used as an intervention; and

(G) A plan for behavior management needs if needs are greater than usual for the program.

(2) Assessment and Evaluation Report (AER):

(a) A BRS contractor that provides services and placement-related activities in a Shelter, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Basic Rehabilitation, Intensive Residential, Intensive Rehabilitation or Intensive Behavioral Support program shall, and require that its BRS providers:

(A) Ensure that a social service staff member conducts a comprehensive assessment of the BRS client and completes a written AER; and

(B) Submit the written AER to the caseworker within 45 days of the BRS client’s admission to its program.

(b) The BRS contractor and the BRS provider types listed in section (2)(a) of this rule must ensure that the AER includes information about the BRS client regarding the following domains:

(A) Legal custody and basis for custody;

(B) Medical information including prescribed medications and dosages;

(D) Mental health information;

(E) Alcohol and drug use both current and historical;

(F) Educational needs;

(G) Vocational services, if the BRS client is 14 years of age or older;

(H) Social living skills; and

(I) Placement plans including home visits, transitional visits, anticipated discharge date, and placement resources.

(c) The BRS contractor shall, and require that its BRS provider types listed in section (2)(a) of this rule, ensure that the AER describes the following:

(A) Identified problems, reason for referral or placement, and pertinent historical information;

(B) The BRS client’s behaviors, response to current services, and strengths and assets;

(D) A plan for behavior management needs if needs are greater than usual for the program;

(E) Identification of any service goals; and

(F) Identified needs by assessment and history.

(d) The BRS contractor shall, and require that its BRS provider types listed in section (2)(a) of this rule, ensure that the Abbreviated AERs meet the following requirements:

(A) If a BRS client is transferred to the current BRS program from another BRS program and the client’s most recent AER is less than 90 days old, the current BRS contractor or BRS provider may submit an abbreviated AER to the caseworker within 30 days of the client’s transfer to its program instead of the AER required in section (2) of this rule;

(B) The BRS contractor shall, and require that its BRS provider types listed in section (2)(a) of this rule, ensure that an abbreviated AER includes at minimum the information in section (2)(b)(A) of this rule and any other specific information requested by the caseworker. If the information is available, the BRS contractor or BRS provider must also include the information in section (2)(b)(B) through (D) of this rule.

(3) Master Service Plan (MSP):

(a) A BRS contractor that provides services and placement-related activities in a Shelter, Community Step Down, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Rehabilitation, Intensive Residential, Intensive Rehabilitation, or Intensive Behavioral Support program shall, and require that its BRS provider:

(A) Ensure that a social service staff member completes a written individualized MSP within 45 days of the BRS client’s admission to its program;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP;

(C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP;

(D) Obtain written approval of the MSP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and

(E) Provide the services identified in the MSP.

(b) The BRS contractor shall, and require that its BRS provider types listed in section (3)(a) of this rule, ensure that the MSP includes goals that are measurable and attainable within a specified time frame and address at minimum the following domains where need is indicated by the BRS client’s assessment and history:

(A) Legal custody and basis for custody;

(B) Medical information including medications and dosages;

(D) Mental health information;

(E) Alcohol and drug use both current and historical;

(F) Educational needs;

(G) Vocational needs;

(H) Social living skills;

(I) Placement plans including home visits, transitional visits, anticipated discharge date, and placement resources;

(J) Other needs identified in the BRS client’s AER that do not fall in one of the other identified domains above; and

(K) Completion criteria individualized for each BRS client. Completion is defined by progress in acquiring pro-social behaviors, attitudes, and beliefs while in the program, and not engaging in behavior that seriously jeopardizes the safety of staff and other program participants.

(c) The BRS contractor and the BRS provider types listed in section (3)(a) of this rule must ensure that the MSP is individualized and developmentally appropriate and includes:

(A) Specifically stated and prioritized service goals for the BRS client that include the caseworker’s recommendations and goals that the BRS client wants to achieve;

(B) Specific interventions and services its program shall provide to address each goal, including the use of a behavior management system as an intervention and a plan for behavior management needs if needs are greater than usual for the program;

(D) Specifically stated behavioral criteria for evaluating the achievement of goals;

(E) A timeframe for the completion of goals;

(F) The method used to monitor the BRS client’s progress towards completing goals;

(G) Transition goals and planning; and

(H) Aftercare Services, including a detailed description of available services that may be offered to the BRS client. These services can include but are not limited to crisis intervention, service coordination, monitoring, skills training and parent training.

(d) The BRS contractor shall, and require that its BRS provider types listed in section (3)(a) of this rule, clearly list in the MSP those needs identified in a BRS client’s AER that are to be addressed by an outside provider and then identify the outside provider that will be responsible for addressing those needs. The BRS contractor shall, and require that its BRS provider, facilitate the BRS client’s access to other providers whenever needs identified in the AER cannot be met within the scope of the services offered by its program;

(e) The BRS contractor shall, and require that its BRS provider types listed in section (3)(a) of this rule, also describe in the MSP any plan for the BRS client to participate in overnight home visits or transitional visits, including but not limited to documenting when the home visits or transitional visits are to occur, identifying the frequency of the visits (up to a maximum of eight days per month for a combination of home visits and transitional visits), and describing how the visits relate to the BRS client’s goals identified in the MSP. The BRS contractor shall, and require that its BRS provider, make every attempt to schedule home visits and transitional visits so that they do not conflict with services. Any deviation from the approved home visit and transitional visit plan requires prior written approval from the agency.

(4) Master Service Plan 90 Day Updates:

(A) Ensure that a social service staff member reviews and updates in writing the BRS client’s MSP no later than 90 days from the date the MSP was first finalized or the last time it was updated and every 90 days thereafter. Social service staff must review the MSP and update it in writing if necessary, earlier whenever additional information becomes available that suggests that other services should be provided;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP updates;

(C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP updates;

(D) Obtain written approval of an updated MSP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and

(E) Provide the services identified in the most recent MSP update.

(b) The BRS contractor shall, and require that its BRS provider types listed in section (4)(a) of this rule, ensure that the written update to the MSP is individualized and developmentally appropriate and includes at minimum the following:

(A) The BRS client’s progress towards achieving service goals;

(B) The BRS client’s performance on the behavior management system;

(D) Any modifications to services based on the BRS client’s new behaviors or identified needs;

(E) Any changes regarding recommendations, the discharge date, and transition plans;

(F) Aftercare Planning with a detailed description of the services to be delivered to the BRS client and during the aftercare period; and

(G) A summary of incidents involving the BRS client that have occurred since the last time the MSP was updated.

(5) Aftercare and Transition Plan (ATP):

(a) A BRS contractor that provides services and placement-related activities in Community Step Down, Proctor Care, Proctor Enhanced Services, Independent Living, Enhanced Structure Independent Living Program Assessment and Evaluation, Basic Residential, Rehabilitation, Intensive Residential, Intensive Rehabilitation, or Intensive Behavioral Support shall, and require that its BRS provider:

(A) Ensure that a social service staff member develops and completes a written ATP at least 30 days prior to, or when there is insufficient notice, as close as possible to 30 days prior to the BRS client’s planned discharge incorporating information from the latest MSP;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule and members of the service planning team to participate in developing the BRS client’s written ATP;

(C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule and members of the service planning team were provided with the opportunity to participate in developing the written ATP;

(D) Provide a copy of the written ATP to the individuals described in section (1)(a)(B) of this rule and members of the service planning team; and

(E) Obtain written approval of the written ATP from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian.

(b) The BRS contractor shall, and require that its BRS providers listed in section (5)(a) of this rule, ensure that the written ATP describes how the BRS client will successfully transition from its program to the community, specifically addressing the period of 180 days after discharge from its program. The BRS contractor and BRS provider must ensure that the written ATP includes, at minimum, the following:

(A) Identification of the BRS client’s individual needs and unmet goals;

(B) Identification of the aftercare services and supports outside of its program that will be available for the 180-day time-period;

(C) Identification of the individual or entity responsible for providing the aftercare services outside of its program; and

(D) Identification of aftercare services and supports provided by the program to the BRS client that will be available for the 180-day time period. These services may include crisis intervention, service coordination, monitoring, and skills training. Minimum contact schedule is one time per week for the first 30 days, two times per month for the next 60 days, and one time per month for the remaining 90 days. Document the type, duration, and description of contact in the record pertaining to the BRS client.

(E) Schedule for regular telephone contact by BRS provider staff with the BRS client and, as applicable, the BRS client’s family, fictive kin, caseworker, or other identified significant individuals.

(c) The BRS contractor shall and require that its BRS providers listed in section (5)(a) of this rule, provide services identified in the ATP.

(d) The BRS contractor and its BRS provider types listed in section (5)(a) of this rule will not be required to provide aftercare services and supports if the BRS client decline services or when the BRS client transitions to another BRS program. The BRS contractor or BRS provider is still required to complete a written ATP.

(e) The BRS contractor or BRS provider types listed in section (5)(a) of this rule may not be required to provide a written ATP under the following circumstances:

(A) The agency, legal guardian, or custodian removes the BRS client from the program with little or no notice and in a manner not in accordance with the existing ATP;

(B) The BRS client is discharged from the program on an emergency basis due to the BRS client’s behavior, runaway status without a plan to return to the program, or transfer to another program or higher level of care;

(D) The BRS client initiates an immediate voluntary discharge from the program.

(6) For a discharge summary, a BRS contractor that provides services and placement-related activities in a Shelter, Community Step-down, Independent Living program, Enhanced Structure Independent Living program, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Rehabilitation Services, Intensive Residential, Intensive Rehabilitation, Short-Term Stabilization, or Intensive Behavioral Support program shall, and require that its BRS provider, ensure that a social service staff member completes and provides a written discharge summary to the caseworker within 15 days following the BRS client’s planned or actual discharge from its program. The discharge summary must include the BRS client’s progress towards service goals.

(7) Aftercare Summary:

(a) A BRS contractor that provides services and placement-related activities in a Community Step-down, Independent Living, Enhanced Structure Independent Living Program, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Rehabilitation Services, Intensive Residential, Intensive Rehabilitation, Short-Term Stabilization, and Intensive Behavioral Support program shall, and require that its BRS provider:

(A) Ensure that a social service staff member completes and provides a written aftercare summary to the caseworker within 210 days following the BRS client’s discharge from its program;

(B) Summarize the BRS client’s status and progress on the ATP for the 180 days following the client’s discharge from the BRS provider, including but not limited to the client’s adjustment to the community and any further recommendations;

(C) Summarize the specific services provided by the BRS contractor and BRS provider for the 180 days following discharge to include a description of each type of service provided, number of service hours provided per month, and the names of individuals receiving the services.

(b) An aftercare summary is not required if the BRS provider type listed in section (7)(a) of this rule was not required to complete an ATP under circumstances listed in section (5)(e)(A-E) of this rule.

(8) Master Service Plan – Transition (MSP-T):

(a) A BRS contractor that provides services and placement-related activities in an Independent living program or Enhanced Structure Independent Living program shall, and require that its BRS provider:

(A) Ensure that the transition facilitator completes with the BRS client a standardized assessment of independent living skills prior to the development of the MSP-T;

(B) Ensure that a transition facilitator in collaboration with the BRS client completes a written MSP-T within 30 days of the BRS client’s admission to the program;

(D) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-T;

(E) Ensure the MSP-T is individualized and developmentally appropriate and includes:

(i) Specifically stated and prioritized service goals for the BRS client that include the caseworker’s recommendations and goals that the BRS client wants to achieve;

(ii) Specific interventions and services the program shall provide to address each goal, including the use of a behavior management system as an intervention and a plan for behavior management needs if needs are greater than usual for the program;

(iii) Staff responsible for providing the identified services;

(iv) Specifically stated behavioral criteria for evaluating the achievement of goals;

(v) A timeframe for the completion of goals;

(vi) The method used to monitor the BRS client’s progress towards completing goals.

(b) The BRS contractor shall, and require that its BRS provider type listed in section (8)(a) of this rule, obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP-T;

(c) The BRS contractor shall, and require that its BRS provider type listed in section (8)(a) of this rule, obtain and maintain written approval of the MSP-T prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the client’s parent, guardian, or legal custodian;

(d) The BRS contractor shall, and require that its BRS provider type listed in section (8)(a) of this rule, ensure that the MSP-T includes goals that are measurable and attainable within a specified time frame and address at minimum the following domains where need is indicated by an assessment of the BRS client’s referral information and history:

(A) Legal custody and basis for custody;

(B) Medical information including medications and dosages;

(D) Mental health information;

(E) Alcohol and drug use including relapse prevention;

(F) Educational needs;

(G) Vocational needs;

(H) Placement plans including home visits, transitional visits, anticipated discharge date, and placement resources;

(I) Social living skills needs, including barriers to building healthy social support, recreation, and community connection or membership (including planning for supportive relationships);

(J) Independent living skills needs, which may include barriers regarding the use of technology, finances, and consumer awareness, transportation planning and responsibility, and free-time supervision and structure.

(9) Master Service Plan — Transition 30-day Updates:

(a) The BRS contractor of an Independent Living or Enhanced Structure Independent Living program shall, and require that its BRS provider:

(A) Ensure that the transition facilitator in collaboration with the BRS client reviews and updates in writing the BRS client’s MSP-T no later than 30 days from the date the MSP-T was first finalized or the last time it was updated and every 30 days thereafter;

(B) Provide an opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-T update;

(C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP-T updates;

(D) Obtain written approval of an MSP-T update prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and

(E) Provide the services identified in the most recent MSP-T update.

(b) The BRS contractor and its BRS provider type listed in section (9)(a) of this rule, must ensure that the written MSP-T update is individualized and developmentally appropriate and includes at minimum the following:

(A) The BRS client’s progress towards achieving service goals;

(B) The BRS client’s performance on the behavior management system;

(D) Any modifications to services based on the BRS client’s new behaviors or identified needs;

(E) Any changes regarding recommendations, the discharge date, or aftercare and transition plans; and

(F) A summary of incidents involving the BRS client that have occurred since the last MSP-T update.

(10) For an Initial Service Plan – Stabilization (ISP-S), a BRS contractor that provides services and placement-related activities in a Short-term Stabilization program shall, and require that its BRS provider:

(a) Ensure that a social service staff completes a written ISP-S within two business days of the BRS client’s admission to the program;

(b) Provide an opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s ISP-S;

(c) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the ISP-S;

(d) Obtain written approval of the ISP-S prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian;

(e) Provide the services identified in the ISP-S during the BRS client’s first 30 days in the program.

(f) Ensure that the ISP-S is individualized, developmentally appropriate, and based on a thorough assessment of the BRS client’s referral information, and includes at minimum the following:

(A) A plan to address specific behaviors and needs identified in the referral information including the intervention to be used;

(B) A plan for any overnight home visits and transitional visits;

(D) The anticipated type of placement at discharge;

(E) Existing orders for medication and any prescribed treatments for medical conditions, mental health conditions, or substance abuse;

(F) Any type of behavior management system used as an intervention;

(G) A plan for behavior management needs if needs are greater than usual for the program;

(H) Objectives for placement as described by the caseworker; and

(I) Goals that are measurable and attainable within the first 30 days of the BRS client’s placement in the BRS program.

(11) Assessment and Evaluation Report — Stabilization (AER-S):

(a) A BRS contractor that provides services and placement-related activities in a short-term stabilization program shall, and require that its BRS provider, ensure a social service staff member conducts an assessment of each BRS client who is expected to remain in the program for more than 30 days;

(b) A BRS contractor and BRS provider in a short-term stabilization program shall, after conducting the assessment, require that the staff member submit a written AER-S to the BRS client’s caseworker within 30 days from the date the client was admitted into the program. The written AER-S shall include the following information about the BRS client:

(A) A summary of the client’s problems and needs, the reason for referral or placement, and any pertinent historical information;

(B) Identified reasons for behavioral instability;

(D) The BRS client’s behaviors, response to current services, and strengths and assets;

(E) Assessment of BRS client’s characteristics that may require service delivery modifications to ensure successful participation in BRS services;

(F) Significant incidents or interventions or both;

(G) A plan for behavior management needs if needs are greater than usual for the program, if applicable.

(c) The BRS program as described in section (11)(a) of this rule is not required to conduct an assessment or submit a written AER-S, as described in section (11)(b) of this rule, when the BRS client is expected to remain in the program for 30 days or less.

(12) Master Service Plan – Stabilization (MSP-S):

(a) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider:

(A) Ensure that a social service staff completes a written MSP-S within 30 days of the BRS client’s admission to the program;

(B) Provide an opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-S;

(C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP-S;

(D) Obtain written approval of the MSP-S prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian;

(E) Ensure that the MSP-S is individualized and based on the BRS client’s needs identified in the AER-S;

(F) Provide the services identified in the current MSP-S.

(b) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider, ensure that the MSP-S describes the following:

(A) Specifically stated and prioritized service goals for the BRS client based on the AER-S that include the caseworker’s recommendations and goals that the BRS client wants to achieve;

(B) Medical information including medications and dosages.

(c) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider, ensure that the MSP-S is individualized and developmentally appropriate and includes:

(A) Specific interventions and services its program shall provide to address each goal, including the use of a behavior management system as an intervention and a plan for behavior management needs if needs are greater than usual for the program;

(B) Staff responsible for providing the identified services;

(D) A timeframe for the completion of goals;

(E) The method used to monitor the BRS client’s progress towards completing goals;

(F) Aftercare and transition goals and planning, including anticipated discharge date and placement resource;

(G) Completion criteria individualized for each BRS client. Completion is defined by progress in acquiring pro-social behaviors, attitudes, and beliefs while in the program and not engaging in behavior that seriously jeopardizes the safety of staff and other program participants.

(d) For the Assessment and Evaluation Report, the BRS contractor of a short-term stabilization program shall, and require its BRS provider, to identify in the MSP-S those needs identified in a BRS client’s AER-S that will be addressed by an outside provider and identify that provider. The BRS contractor shall, and require that its BRS provider, facilitate the BRS client’s access to other providers whenever needs identified in the AER-S cannot be met within the scope of the services offered by its program;

(e) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider, describe in the MSP-S any plan for the BRS client to participate in overnight home visits and transitional visits, including but not limited to documenting when the home visits and transitional visits are to occur, identifying the frequency of the visits (up to a maximum of eight days per month), and describing how the visits relate to the BRS client’s goals identified in the MSP-S. The BRS contractor shall, and require that its BRS provider, make every attempt to schedule home and transitional visits so that they do not conflict with services. Any deviation from the approved home visit and transitional visit plan requires prior written approval from the BRS client’s caseworker.

(13) Master Service Plan – Stabilization Updates (MSP-S):

(a) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider:

(A) Ensure that a social service staff member reviews and updates in writing the BRS client’s MSP-S no later than 30 days from the date the MSP-S was first finalized or the last time it was updated and every 30 days thereafter. Social service staff must review the MSP-S and update it in writing earlier, if necessary, whenever additional information becomes available that suggests that other services should be provided;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-S updates;

(C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP updates;

(D) Obtain written approval of an updated MSP-S prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and

(E) Provide the services identified in the most recent MSP-S update.

(b) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider, ensure that the written update to the MSP-S is individualized and developmentally appropriate and includes at minimum the following:

(A) The BRS client’s progress towards achieving service goals;

(B) The BRS client’s performance on the behavior management system;

(D) Any changes regarding recommendations, the discharge date, or aftercare and transition plans; and

(E) A summary of incidents involving the BRS client that have occurred since the last time the MSP-S was updated.

(14) Aftercare and Transition Plan - Stabilization (ATP-S):

(a) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider:

(A) Ensure that a social service staff member develops and completes a written ATP-S at least 30 days prior to or as close as possible to the BRS client’s planned discharge;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule and members of the service planning team to participate in developing the BRS client’s written ATP-S;

(D) Provide a copy of the written ATP-S to the individuals described in section (1)(a)(B) of this rule and members of the service planning team; and

(E) Obtain written approval of the written ATP-S from the caseworker and, as applicable and appropriate, the BRS client and the client’s parent, guardian, or legal custodian.

(b) The BRS contractor of a short-term stabilization program shall, and require its BRS provider, ensure the written ATP-S describes how the BRS client is successfully transitioning from its program to the community, specifically addressing the period of 180 days after discharge from its program. The BRS contractor shall, and require that its BRS provider, ensure the written ATP-S includes, at minimum, the following:

(A) Identification of the BRS client’s individual needs and unmet goals;

(B) Identification of the aftercare services and supports outside of its program that are available for the 180-day time-period;

(D) Identification of aftercare services and supports provided by the BRS program to the BRS client that will be available for the 180-day time period. These services may include crisis intervention, service coordination, monitoring, and skills training. Minimum contact schedule is one time per week for the first 30 days, two times per month for the next 60 days, and one time per month for the remaining 90 days. Document the type, duration, and description of contact in the record pertaining to the BRS client.

(c) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider, complete an ATP-S for BRS clients who are being discharged home or into a non-BRS foster care placement;

(d) The BRS contractor or BRS provider will not be required to provide aftercare services and supports if the BRS client decline services as documented in the ATP-S. The BRS contractor or BRS provider is still required to complete an ATP-S.

(e) The BRS contractor or BRS provider of a short-term stabilization program may not be required to provide a written ATP-S under the following circumstances:

(A) The agency, legal guardian, or custodian removes the BRS client from the program with little or no notice and in a manner not in accordance with the current service plan;

(15) The BRS contractor shall, and require that its BRS provider, ensure that all BRS service plans described in this rule are developed and maintained in the BRS client’s case file in accordance with the timeframes and criteria in this rule, unless otherwise exempted.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0080 Services

(1) The BRS contractor shall, and require that its BRS provider, provide services to the BRS client in accordance with the BRS client’s service plan.

(2) BRS contractor staff shall, and require that its BRS provider, staff structure and directly supervise all services.

(3) Types of Services:

(a) Milieu Therapy:

(A) The BRS contractor shall, and require that its BRS provider, provide the BRS client structured activities and planned interventions designed to normalize psycho-social development, promote safety, stabilize environment, and assist in responding in developmentally appropriate ways;

(B) The program’s staff shall monitor the BRS client in these activities, which include developmental, recreational, academic, rehabilitative, or other productive work;

(C) Milieu therapy occurs in concert with one of the other types of services. Because milieu therapy must occur in concert with another BRS service, the BRS contractor may not and shall ensure that its BRS provider does not count milieu therapy in the number of hours of BRS services provided to the BRS client per week.

(b) For crisis counseling, the BRS contractor shall, and require that its BRS provider, provide the BRS client counseling on a 24-hour basis to stabilize the client’s behavior until the problem can be resolved or assessed and treated by a qualified mental health professional or licensed medical practitioner;

(c) For individual and group counseling, the BRS contractor shall, and require that its BRS provider, provide face-to-face individual or group counseling sessions to the BRS client that are designed to remediate the problem behaviors identified in the client’s service plan;

(d) For parent training, the BRS contractor shall, and require that its BRS provider, provide planned activities or interventions (face-to-face or by telephone) to the BRS client’s family or identified aftercare resource family. Parent training is designed to assist the family in identifying the specific needs of the BRS client, support the client’s efforts to change, and improve and strengthen parenting knowledge or skills indicated in the service plan as being necessary for the client to return home or to another community living resource;

(e) For skills-training, the BRS contractor shall, and require that its BRS provider, provide the BRS client planned individual or group sessions using evidence-based or evidence-informed approaches or models designed to improve specific areas of functioning in the client’s daily living as identified in the service plan. Skills-training may be designed to develop appropriate social and emotional behaviors, improve peer and family relationships, improve self-care, encourage conflict resolution, reduce aggression, improve anger control, and reduce or eliminate impulse and conduct disorders.

(f) For Face-to-face services described in sections (3)(c-d) of this rule the BRS contractor shall, and require it’s BRS provider to, provide them in accordance with the definition standards described in OAR 410-170-0020(30). Any barriers BRS contractors or their BRS providers encounter when attempting to meet these standards including, but not limited to, temporary technical issues, health and safety precautions, or client preference should be documented in service notes and attempts should be made to mitigate barriers as they arise.

(4) Telehealth for Behavior Rehabilitation Services:

(a) To utilize telehealth for services required by the BRS program, the BRS contractor and BRS providers shall:

(A) Comply with Telehealth for Behavioral Health requirements described in OAR 410-172-0850;

(B) Comply with prioritized list of health services guidelines for telephone and e-mail consultation described in OAR 410-141-3830; and

(b) The BRS contractor and BRS providers shall develop written telehealth policy that complies with section (4)(a)(A-C) of this rule. At minimum, the policy shall describe:

(A) The circumstances the provider may provide BRS services via telehealth;

(B) The telecommunication technologies the BRS contractor or BRS provider has implemented to deliver services via telehealth; and

(C) The process to obtain an individual’s informed consent in accordance with ORS 107.154, 179.505, 179.507, 192.515, including a sample form.

(c) The BRS contractor and BRS providers may utilize telehealth for services that require a face-to-face setting when there is a documented barrier to providing in-person services, as follows:

(A) Services via telehealth shall be provided by a qualified program staff within their scope of position;

(B) Service notes for phone, individual or group counseling shall follow the same criteria as face-to-face counseling and identify the session was conducted by telehealth and the reason for the use of telehealth; and

(D) Any barriers to meeting the standards set in the face-to-face definition found in OAR 410-170-0020(30), including but not limited to temporary technical issues, health and safety precautions, or client preference should be documented in service notes and attempts should be made to mitigate barriers as they arise.

(5) The BRS contractor shall, and require that its BRS provider:

(a) Provide a combination of services necessary to comply with the BRS client’s service plan and the requirements in OAR 410-170-0090 for the appropriate BRS type of care;

(b) Create and maintain written documentation describing the services provided to each BRS client that includes at a minimum the following information:

(A) Name of the BRS client;

(B) Date of service;

(D) Length of time staff spent providing the service to the BRS client;

(E) Description of the service provided; and

(F) Description of the BRS client’s participation in the service.

(c) Create and maintain a written weekly record in each BRS client’s case file with the total number of service hours provided each day to the client and a breakdown of the number of hours spent providing each type of service described in section (3) of this rule; and

(d) Ensure that social service staff review the documentation described in this section each week for quality, content, and appropriateness with the BRS client’s service plan.

History

Statutory/Other Authority: ORS 413.042, ORS 414.065 & ORS 743A.058
Statutes/Other Implemented: ORS 414.065
DMAP 48-2020, amend filed 09/21/2020, effective 09/21/2020
DMAP 31-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 09/21/2020
DMAP 14-2020, temporary amend filed 03/26/2020, effective 03/26/2020 through 09/21/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0090 BRS Types of Care

(1) Shelter, Community Step-Down, and Independent Living Program:

(a) The BRS contractor or BRS provider may use either a residential care model or proctor care model for these BRS types of care;

(b) The BRS contractor providing one of these BRS types of care shall, and require that its BRS provider, ensure that a minimum of six hours of services are available per week to each BRS client as follows:

(A) One hour of individual counseling or individual skills-training provided by social service staff; and

(B) Five hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(d) The BRS client is placed in a community step-down type of care from a higher BRS level of care following a thorough Assessment and Evaluation Report and when the BRS client requires only six BRS hours of service but the same level of BRS structure and support;

(e) The BRS client placed in an independent living program type of care requires a structured, supervised setting prior to transitioning to a supported community placement or living independently.

(2) Enhanced Structure Independent Living Program:

(a) This BRS type of care follows a residential care model;

(b) The BRS contractor providing this BRS type of care shall, and require that its BRS provider, ensure that a minimum of six hours of services are available per week to each BRS client as follows:

(A) One hour of individual counseling or individual skills-training provided by social service staff; and

(B) Five hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(c) The BRS client placed in an enhanced structure independent living program type of care requires a structured, supervised setting with increased staff supervision and support prior to transitioning to a supported community placement or living independently.

(d) The BRS client placed in an independent living program type of care requires a structured, supervised setting prior to transitioning to a supported community placement or independent living.

(3) Proctor Care, Proctor Enhanced Services, Assessment and Evaluation Proctor:

(a) These BRS types of care follow a proctor care model;

(b) The BRS contractor providing one of these BRS types of care shall, and require that its BRS provider, ensure that a minimum of 11 hours of services are available per week to each BRS client as follows:

(A) Two hours of individual counseling or individual skills-training, one of which is provided by social service staff; and

(B) Nine hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(c) The BRS client placed in proctor care types of care requires structure, behavior management, and support services to develop the skills necessary to be successful in a less restrictive home setting with an approved proctor foster parent;

(d) The BRS client placed in proctor enhanced services types of care requires enhanced structure during the daytime hours. This level of care provides the structure of day treatment for necessary skill development with a less restrictive home setting with an approved proctor foster parent;

(e) The BRS client is placed in assessment and evaluation proctor type of care to identify deficiencies and develop necessary skills.

(4) Basic Residential, Rehabilitation Services, Intensive Residential, Intensive Rehabilitation Services, Assessment and Evaluation Residential, Short-Term Stabilization:

(a) These types of care follow a residential care model. The BRS contractor shall, and require that its BRS provider, provide 24-hour supervision of the BRS client by ensuring that at least one direct care staff is on duty and awake whenever a BRS client is present in its program;

(b) The BRS contractor providing these BRS types of care shall, and require that its BRS provider, ensure that a minimum of 11 hours of services are available per week to each BRS client as follows:

(A) Two hours of either individual counseling or individual skills-training, one of which is provided by social service staff; and

(B) Nine hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(c) The BRS client placed in basic residential BRS types of care requires the structure, behavior management, and support services of a residential care model for necessary skill development;

(d) The BRS client placed in rehabilitation services types of care requires the structure, behavior management, and support services of a residential care model for necessary skill development;

(e) The BRS client is placed in assessment and evaluation residential BRS type of care to identify deficiencies and develop necessary skills;

(f) The BRS client placed in intensive residential or intensive rehabilitation services BRS types of care requires more intensive structure, behavior management, and support services than a BRS client in the basic residential or rehabilitation BRS types of care;

(g) The BRS client placed in short-term stabilization BRS type of care requires short-term intervention to provide behavioral stabilization.

(5) Intensive Behavioral Support:

(a) This type of care follows a residential care model. The BRS contractor shall, and require that its BRS provider, provide 24-hour supervision of the BRS client by ensuring that at least one direct care staff is on duty and awake whenever a BRS client is present in its program;

(b) The BRS contractor providing this level of care shall, and require that its BRS provider, ensure that a minimum of 11 hours of services are available per week to each BRS client as follows:

(A) Three hours of individual counseling or individual skills-training, two hours of which are provided by social service staff; and

(B) Eight hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(c) BRS clients placed in the intensive behavioral support type of care have difficulty re-regulating their emotions due to the presence of complex developmental trauma or other mental health concerns. They require skill training and intensive behavioral support.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0100 Placement-Related Activities for the Authority’s BRS Contractors and BRS Providers

(1) In cases where the Authority is the agency, the BRS contractor shall, and require that its BRS provider, provide the following placement-related activities and all facilities, personnel, materials, equipment, supplies and services, and transportation necessary to provide those activities including but not limited to:

(a) For transportation, the BRS contractor shall, and require that its BRS provider, be responsible for the transportation of the BRS client to attend school to the extent not provided by the school district. For transportation to medical, dental, and therapeutic appointments to the extent not provided through the Oregon Health Plan; to recreational and community activities; to places of employment; and to shop for incidental items;

(b) For educational and vocational activities, the BRS contractor shall, and require that its BRS provider, have a system in place to meet the educational and vocational needs of the BRS client in its program either on-site or at an off-site location or a combination of the two;

(A) The BRS contractor shall, and require that its BRS provider, provide recreation time for the BRS client daily and offer activities that are varied in type to allow BRS clients to obtain new experiences. The BRS contractor shall, and require that its BRS provider, document recreation as having been provided by recording the type of activity the BRS client participated in and the date it occurred;

(B) The BRS contractor shall, and require that its BRS provider, provide each BRS client at least one opportunity per week to participate in recreational activities in the community, unless the BRS client is clearly unable to participate in offsite activities due to safety issues. If a BRS client is restricted from participation in community recreation, the BRS contractor shall, and require that its BRS provider, document the reason in the BRS client’s case file, and the reason must be reviewed regularly to ensure that the BRS client is not unnecessarily restricted from offsite activities. The BRS contractor shall, and require that its BRS provider, offer any BRS client who is restricted from community activities alternative opportunities for recreation on-site;

(C) The BRS contractor shall, and require that its BRS provider, provide access to or make available social and cultural activities for the BRS clients as part of the therapeutic milieu of the program. These activities are to promote the BRS client’s normal development and help broaden the BRS client’s understanding and appreciation of the community, arts, environment, and other cultural groups;

(D) The BRS contractor must not, and ensure that its BRS provider does not, permit BRS clients to participate in recreational activities that present a higher level of risk to BRS clients without pre-approval by the caseworker. This applies to activities that require a moderate to high level of technical expertise to perform safely, present environmental hazards, or where special certification or training is recommended or required such as: whitewater rafting, rock climbing, ropes courses, activities on or in any body of water where a certified lifeguard is not present and on duty, mountain climbing, and using motorized yard equipment.

(d) The BRS contractor shall, and require that its BRS provider, provide adequate opportunities for the BRS clients to complete homework assignments with assistance from staff if needed.

(2) The BRS contractor shall, and require that its BRS provider, facilitate the BRS client’s access to other providers whenever identified needs are not met within the scope of services offered by the program. If health care services are needed but the program is unable to access the needed services for the BRS client, the BRS contractor shall, and require that its BRS provider, immediately notify the caseworker about this in writing and document its unsuccessful efforts to access healthcare for the BRS client in the BRS client’s case file:

(a) If there is no record that the BRS client received a physical examination within the six months immediately prior to the BRS client’s placement with its program, the BRS contractor shall, and require that its BRS provider, ensure or make every effort to ensure that the BRS client receives a general medical checkup consistent with the OHP or health insurance allowances within 30 days of placement. The BRS contractor shall, and require that its BRS provider, keep documentation of this procedure in the BRS client’s file and send a copy to the BRS client’s caseworker;

(b) The BRS contractor shall, and require that its BRS provider, ensure that services are provided for each BRS client’s mental health, physical health (including alcohol and drug treatment services), dental, and vision needs. This does not include paying the cost of services or medications that are covered by the OHP or by the BRS client’s third party private insurance coverage. For services or medications not covered by OHP or third party private insurance, the BRS contractor shall, and ensure that its BRS provider, notify and work with the caseworker to resolve payment issues;

(c) The BRS contractor shall, and require that its BRS provider, administer and monitor medications consistent with all applicable licensing rules and the program’s own medication management policy.

(3) The Authority’s BRS contractor, if not also the BRS provider, is responsible for ensuring its BRS provider provides the placement-related activities to the BRS client as described in this rule.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0110 Billing and Payment for Services and Placement-Related Activities

Effective July 1, 2025:

(1) The BRS contractor is compensated for a billable care day (service and placement-related activities rates) on a fee-for-service basis, except as otherwise provided for in these rules. The Authority does not make payments for any calendar day that does not meet the definition of a billable care day under this rule.

(2) Billable care day rates are provided in the “BRS Rates Table,” dated July 1, 2025, which is adopted as Exhibit 1 and incorporated by reference into this rule. The BRS Rates Table is available at http://www.oregon.gov/oha/HSD/OHP/Pages/Policy-BRS.aspx. A printed copy may be obtained from the agency. BRS contractors not meeting the QRTP requirements will be paid at the non-QRTP rate.

(3) Billable Care Day:

(a) For purposes of computing a billable care day, the BRS client must be in the direct care of the BRS contractor or BRS provider at 11:59 p.m. of that day, be on runaway status as defined in this rule or be on an authorized home or transitional visit in accordance with section (4) of this rule;

(b) A billable care day does not include any day where the BRS client is in detention, an inpatient in a hospital, or has not yet entered or is discharged from the BRS contractor’s or BRS provider’s program;

(c) A billable care day does not include any day in which a BRS client is on runaway status and the BRS contractor or BRS provider was responsible for less than an accumulated period of 8 hours for the primary care, support, safety, and well-being of the BRS client.

(4) Home and Transitional Visits:

(a) The BRS contractor and BRS provider shall include only a maximum of eight (8) calendar days of a combination of home and transitional visits in a month, as billable care days;

(b) In order to qualify as an authorized home or transitional visit day, the BRS contractor and BRS provider must:

(A) Ensure that the home or transitional visit is tied to the BRS client’s service plan;

(B) Work with the BRS client and the BRS client’s family, including fictive kin, or aftercare resource on goals for the home or transitional visit and receive regular reports from the family or aftercare resource on the BRS client’s progress while on the visit;

(C) Have staff available to answer calls from the BRS client and BRS client’s family, including fictive kin, or aftercare resource and to provide services to the BRS client during the time planned for the home or transitional visit if the need arises;

(D) Document communications with the BRS client’s family, including fictive kin, or aftercare resource; and

(E) Document the BRS client’s progress on goals set for the home or transitional visits.

(5) Invoice form:

(a) The BRS contractor shall submit a monthly billing form to the agency in a format acceptable to the agency on or after the first day of the month following the month in which it provided services and placement-related activities to the BRS client. The billing form must specify the number of billable care days provided to each BRS client in that month;

(b) The BRS contractor shall provide upon request, in a format that meets the agency’s approval, written documentation of each BRS client’s location for each day claimed as a billable care day;

(6) Payment for a Billable Care Day:

(a) The agency shall pay the service and placement related activities rates to the BRS contractor for each billable care day in accordance with the BRS Rates Table described in section (2) of this rule;

(b) Notwithstanding section (6)(a) of this rule, the Authority shall pay only the service rate for each billable care day to a public child-caring agency who by rule or contract provides the local match share for Medicaid claims under OAR 410-120-0035 and 42 CFR 433 Subpart B. The Authority may not pay the placement related activities rate for each billable care day to these types of public child-caring agencies;

(A) The BRS contractor and the BRS provider are subject to Medicaid billing and payment requirements in these rules and the Authority’s general rules (OAR Chapter 410, Division 120);

(B) Payment using Medicaid and CHIP funds may be made only to the originating BRS contractor and not to the aftercare resource.

(d) To be eligible as a QRTP and receive the QRTP rate, the BRS contractor and the BRS provider are required to:

(A) Meet the QRTP definition in OAR 410-170-0020; and

(B) Submit accreditation documentation in writing annually to the contract administrator; and

(7) Third Party Resources:

(a) The Authority’s BRS contractors must make reasonable efforts to obtain payment first from other resources consistent with OAR 410-120-1280;

(b) The Department’s and OYA’s BRS contractors are not required to review or pursue third party resources. The Department and OYA must make reasonable efforts to obtain payment first from other resources consistent with OAR 410-120-1280 for Medicaid-eligible BRS clients.

(8) Public child-caring agencies who are responsible by rule or contract for the local match share portion of eligible Medicaid claims must comply with OAR 410-120-0035 and 42 CFR 433 Subpart B.

(9) In cases where the BRS contractor is not also the BRS provider, the BRS contractor is responsible for compensating the BRS provider for billable care days pursuant to the agency-approved subcontract between the BRS contractor and the BRS provider.

(10) The Authority may not be financially responsible for the payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid or CHIP program. If the Authority previously paid the agency or BRS contractor for any claim that CMS disallows, the payment shall be recouped pursuant to OAR 410-120-1397. The Authority shall recoup or recover any other overpayments as described in OAR 410-120-1397 and 943-120-0350 and 943-120-1505.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 84-2025, amend filed 12/02/2025, effective 12/02/2025
DMAP 53-2025, temporary amend filed 06/25/2025, effective 07/01/2025 through 12/27/2025
DMAP 92-2023, amend filed 12/21/2023, effective 12/27/2023
DMAP 53-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 5-2022, amend filed 01/12/2022, effective 01/12/2022
DMAP 32-2021, temporary amend filed 07/22/2021, effective 07/22/2021 through 01/17/2022
DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020
DMAP 34-2020, temporary amend filed 07/01/2020, effective 07/01/2020 through 12/27/2020
DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020
DMAP 45-2019, amend filed 11/06/2019, effective 11/14/2019
DMAP 22-2019, temporary amend filed 06/21/2019, effective 07/01/2019 through 12/27/2019
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 3-2018, amend filed 01/10/2018, effective 01/10/2018
DMAP 30-2017(Temp), f. & cert. ef. 7-25-17 thru 1-20-18
DMAP 64-2016, f. 11-23-16, cert. ef. 11-29-16
DMAP 25-2016(Temp), f. & cert. ef. 6-3-16 thru 11-29-16
DMAP 8-2016, f. & cert. ef. 2-23-16
DMAP 4-2016(Temp), f. 2-5-16, cert. ef. 2-7-16 thru 8-4-16
DMAP 42-2015(Temp), f. & cert. ef. 8-11-15 thru 2-6-16
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Or. Admin. R. 410-170-0120 Compliance Reviews and Sanctions

(1) The BRS contractor shall cooperate and ensure its BRS providers cooperate with program compliance reviews or audits conducted by any federal or state or local governmental agency or entity related to the BRS program.

(2) The Authority or agency or both shall conduct compliance reviews periodically, including but not limited to review of documentation and onsite inspections.

(3) If the Authority determines that the BRS contractor is not in compliance with its contract to provide BRS services or placement-related activities, including but not limited to non-compliance with state or federal law or regulation, then the Authority may:

(a) Provide technical assistance;

(b) Require the BRS contractor working with its BRS provider to develop and implement a corrective action plan;

(d) Pursue any other remedy authorized by state or federal law; or

(e) Pursue any combination of the above.

(4) If the Authority determines that the BRS contractor or the BRS provider is not in compliance with state or federal law or regulation then in addition to pursuing any contract remedy, the Authority may:

(a) Provide technical assistance;

(b) Require the BRS contractor working with its BRS provider to develop and implement a corrective action plan;

(c) Refer the case to an appropriate licensing or other federal or state or local oversight governmental agency or entity;

(d) Pursue any other remedy authorized by state or federal law; or

(e) Pursue any combination of the above.

(5) In addition to the remedies provided in sections (3) and (4) above, if the Authority determines that the BRS contractor or the BRS provider is not in compliance with state or federal law or regulation related to Medicaid services, then the Authority may:

(a) Impose sanctions pursuant to OAR 410-120-1400 and 410-120-1460;

(b) Recover an overpayment pursuant to OAR 410-120-1397; or

(6) Overpayment:

(a) When an overpayment is identified, the Authority shall notify the BRS contractor or BRS provider in writing. The overpayment amount shall be determined at the Authority’s discretion through direct examination of claims, statistical sampling and extrapolation techniques, or other means. Procedures for recovery of funds are as described in OAR 410-120-1397 or by applicable contract language;

(b) When a BRS contractor or BRS provider discovers that they requested and may have received reimbursement not in compliance with all applicable rules, they shall contact the Division’s Medicaid Policy Unit and Office of Payment Accuracy and Recovery (OPAR) promptly to report the possible inappropriate payment and discuss how the appropriateness shall be determined as well as programmatic changes and other notifications to be made.

(7) The BRS contractor or the BRS provider may appeal an Authority’s notice of action for sanctions or overpayments under the appeal processes specified in the notice and applicable administrative rules for the Authority.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Division 172 MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES

Or. Admin. R. 410-172-0600 Temporary rule language in effect until 02/15/2027. Acronyms and Definitions

The acronyms and definitions listed in this rule apply to all of the administrative rules included in this chapter 410, division 172 Medicaid Payment for Behavioral Health Services. However, there may be additional acronyms and definitions included in and apply to other specific rules within the division 172 Rules.

(1) “Activities of Daily Living (ADLs)” means the functional activities required by an individual for continued well-being, that are essential for health and safety. ADLs relate to the following functional categories: eating, dressing and grooming, bathing and personal hygiene, transferring (including mobility and ambulation), and toileting (including elimination and maintaining continence). Specific ADLs within these categories are outlined in other rules in this division.

(2) "Adult" means an individual 18 years of age or older or an emancipated minor. An individual with Medicaid eligibility who needs services specific to children, adolescents, or young adults in transition shall be considered a child until age 21 for the purposes of these rules. Adults who are between the ages of 18 and 21 who are considered children for purposes of these rules shall have all rights afforded to adults as specified in these rules.

(3) “ASAM PPC” means the most current publication of the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-related Disorders, which is a clinical guide used in matching individuals to appropriate levels of care.

(4) “Authority” means the Oregon Health Authority, the agency established in ORS 413 that administers the funds for Titles XIX and XXI of the Social Security Act, or its designee. It is the single state agency for the administration of the medical assistance program under ORS 414. For purposes of these rules, the agencies under the authority of the Oregon Health Authority are the Public Health Division, Health Systems Division, External Relations, Health Policy and Analytics, Fiscal and Operations, Office of Equity and Inclusion, and the Oregon State Hospital.

(5) "Authorized Representative" means, for purposes of the division 172 Rules only, unless expressly defined otherwise in another specific rule in the division 172 Rules, one of the following:

(a) A minor child’s parent or, as defined below in this rule, if applicable, a minor child’s legal representative;

(b) An individual’s legal representative as defined in this rule; or

(A) Age 18 or older;

(B) Is not incapacitated;

(C) Not a provider paid to provide any health services the individual receives or may receive through Oregon Health Plan, including without limitation personal care services or other home and community- based services, except as permitted under ORS 127.635(3); and

(D) Appointed to act on behalf of the individual in making decisions on matters pertaining to the provision of planning and implementation of health care services and supports including, without limitation, personal care services. Appointment by the individual must be made in writing or another method that clearly indicates the individual has freely chosen the identified person as their authorized representative. A person appointed by the individual or the individual’s legal representative may include, without limitation:

(i) A person designated by the individual as having power of attorney under ORS 127.002 through 127.045; or

(ii) a person designated as a health care representative as defined in 127.505 and appointed in accordance with ORS 127.510.

(6) “Behavioral Health” means mental health, mental illness, addiction disorders and substance use disorders.

(7) “Behavioral Health Services” means medically appropriate services rendered or made available to a recipient for treatment of a behavioral health diagnosis.

(8) "Child" means an individual under the age of 18. An individual with Medicaid eligibility who needs services specific to children, adolescents, or young adults in transition shall be considered a child until age 21 for purposes of these rules.

(9) “Community Mental Health Program (CMHP)” means an entity that is responsible for planning and delivery of services for persons with substance use disorders or a mental health diagnosis, operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with the Division as defined in OAR 309-019-0105.

(10) “Cueing" means giving verbal direction or visual clues and encouragement during the activity to help the individual complete activities without hands-on assistance and may include redirection.

(11) "Delegated Nursing Task" means a registered nurse (RN) authorizes a person as described in OAR 851-047-0000 who is not licensed to provide or perform a nursing task. In accordance to OAR chapter 851 division 047, the RN shall, prior to issuing written authorization of a delegated nursing task, assess a specific eligible individual’s care needs, evaluate the person's ability to perform the specific nursing task, provide the person with education and training to perform the nursing task, and supervise and re-evaluate the individual and the person performing the task.

(12) "Department" means the Oregon Department of Human Services (ODHS).

(13) "Designee" means an organization with which the Authority contracts or has an interagency agreement.

(14) "Disability" means a physical, cognitive, or mental health impairment which, for an individual, constitutes or results in a functional limitation in one or more of the activities of daily living described in OAR 410-172-0780.

(15) “Division” means the Health Systems Division of the Oregon Health Authority, or its designee.

(16) “Family Home” means a dwelling, either through an informal arrangement or property manager’s rental agreement, owned or rented by a relative of the Individual, where the Individuals name is not on the agreement.

(17) “Face to Face” means a personal interaction where both words can be heard and facial expressions can be seen in person or through telehealth services where there is a live streaming audio and video, if medically appropriate.

(18) "Guardian" means a person who has been appointed by a court to promote and protect the well-being of an individual in keeping with ORS 125.305.

(19) "Hands-on" means a provider physically performs all or part of an activity because the individual is unable to do so.

(20) “Home” means a dwelling the Individual owns or rents with a formal written arrangement (mortgage, deed, rental agreement, etc.) that includes the Individual’s name and a legally enforceable agreement offering protections against unlawful eviction, substantially similar to the Oregon’s landlord tenant laws.

(21) “Immediate Family” means spouses of individuals and parents of minor individuals, including stepparents who are legally responsible for minor children. Immediate family members of an individual are prohibited from working as a provider for that individual.

(22) “In-Person” means meeting with someone in the same physical location rather than talking on the phone, e-mailing, or writing to the person.

(23) “Instrumental Activities of Daily Living (IADLs)” means self-management activities performed by an individual on a day-to-day basis that are more complex than Activities of Daily Living and support an individual’s health, safety, well-being, and ability to live independently in the community. Instrumental Activities of Daily Living include, but are not limited to meal preparation, light housework, laundry, medication management, transportation, shopping, and money management. Specific IADLs within these categories are described in other rules in this division.

(24) “Independent and Qualified Agent (IQA)” means an entity meeting the provider qualification requirements identified in 42 CFR §441.730 and under contract with the Authority to make eligibility determinations, perform functional needs assessments, develop service-plans, and complete independent psychiatric reviews.

(25) “Home and Community Based Services (HCBS)” means services and supports that assist eligible individuals to remain in their home and community in accordance with the Code of Federal Regulations, approved Medicaid State Plan authorities, and Oregon Administrative Rules.

(26) "Legal Representative" means a person who has been lawfully designated by court order to make financial, health care, or other decisions for another individual.

(a) A legal representative may be a:

(A) Guardian as defined in section (18) of this rule; or

(B) A Health Care Representative as defined in and appointed in accordance with ORS 127.505(13)(c).

(b) A legal representative only has authority to act within the scope and limits of their authority as designated by the court order or other agreement authorized by the court.

(27) "Medicaid OHP Plus Benefit Package" means:

(a) Modified Adjusted Gross Income (MAGI) Medicaid/CHIP as defined at OAR 410-200-0015(58);

(b) Oregon Supplemental Income Program Medical (OSIPM) as defined at OAR 410-200-0015(60).

(c) Any other Oregon Health Plan (OHP) Plus eligibility category authorized by the Authority that includes coverage for State Plan Personal Care services.

(28) “Level of Care” means the type, frequency, and duration of medically appropriate services provided to a recipient of behavioral health services.

(29) “Level of Care Determination” means the standardized process implemented to establish the type, frequency, and duration of medically appropriate services required to treat a diagnosed behavioral health condition.

(30) "Licensed Medical Practitioner (LMP)” means program staff who meet the following minimum qualifications:

(a) Physician licensed to practice in the State of Oregon; or

(b) Nurse practitioner licensed to practice in the State of Oregon; or

(d) Whose training, experience, and competence demonstrate the ability to conduct a mental health assessment and provide medication management.

(31) "Medicaid" means the federal grant-in-aid program to state governments to provide medical assistance to eligible individuals under Title XIX of the Social Security Act.

(32) “Natural Support” means resources and supports (e.g., relatives, friends, significant others, neighbors, roommates, or the community associates) who voluntarily provide services and supports to an individual without the expectation of compensation. Natural supports are identified in collaboration with the individual and the potential "natural support." The natural support is required to have the skills, knowledge, and ability to provide the needed services and supports and shall be identified within the individual’s service plan.

(33) “Oregon Health Plan (OHP)” means the services included in the Authority’s medical assistance programs, including without limitation, Medicaid and Healthier Oregon.

(34) “Personal Care Services” means the IADLs and ADLS provided by a personal care attendant or a direct support worker to an individual in their home or other non-institutional community location outside the individual’s home. Individuals receiving inpatient services or who are residents of a hospital, nursing facility, intermediate care facility or institution are not eligible to receive personal care services under this Division 172 Rule Set.

(35) “Recovery Assistant” means a provider who provides a flexible range of services. Recovery assistants provide face-to-face services in accordance with a service plan that enables a participant to maintain a home or apartment, encourages the use of existing natural supports, and fosters involvement in treatment, social, and community activities. A recovery assistant shall:

(a) Be at least 18 years old;

(b) Meet the background check requirements described in OAR 950-060-0070;

(36) "Redirection" means to divert the individual from one activity to another activity.

(37) "Relative" means a person, excluding an individual's spouse, who is related to the individual by blood, marriage, or adoption.

(38) "Service Plan" means a comprehensive plan for services and supports provided to or coordinated for an individual and their family, as applicable, that is reflective of the assessment and the intended outcomes of service.

(39) “Spouse” means an individual who is legally married to another individual.

(40) “State Medicaid Plan” means the written agreement between the state of Oregon and the federal government that details how the Authority will administer the state’s Medicaid program in compliance with federal law. The State Medicaid Plan serves as the basis for the Authority’s administration of its other medical assistance program. The State Medicaid Plan may also be referred to as the “State Plan”

(41) "Sub-Acute Care Facility" means a care center or facility that provides short-term rehabilitation and complex medical services to an individual with a condition that does not require acute hospital care but prevents the individual from being discharged to their home.

(42) “Supervision” means, along with cueing, helping the individual know when or how to carry out the task. Supervision may be in the form of monitoring, set-up, reassurance, or stand-by to ensure the individual completes the task. Need for assistance may not be based on possible or preventative measures:

(a) "Monitoring" means a provider observes an individual to determine if assistance is needed;

(b) “Set-up" means the preparation, cleaning, and maintenance of personal effects, supplies, assistive devices, or equipment so an individual may perform an activity;

(d) "Stand-by" means a provider is at the side of an individual ready to step in and take over the task if the individual is unable to complete the task independently.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065, 430.705 & 430.715
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 22-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 107-2024, minor correction filed 06/12/2024, effective 06/12/2024
DMAP 103-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0610 Provider Enrollment

(1) Providers shall be enrolled with the Division as a behavioral health provider. Paid providers of behavioral health services shall possess a current and valid license, letter, or certificate.

(2) Providers shall provide services within the scope of professional standards and practice defined by the providers licensing board or certifying organization.

(3) Providers shall meet all requirements in OAR 410-120-1260 (Medical Assistance Programs Provider Enrollment), OAR 943-120-0310 (Provider Requirements), and OAR 943-120-0320 (Provider Enrollment).

(4) Providers shall not be included on any US Office of Inspector General Exclusion lists.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0620 Documentation Standards

(1) OHP providers shall maintain records that fully support the extent of services for which payment has been requested and provide the records to the Division upon request.

(2) All records shall document the specific service provided, the number of services comprising the service provided, the extent of the service provided, the dates on which the service was provided, and the individual who provided the service.

(3) Clinical records shall document the recipient’s diagnosis and the medical need for the service.

(4) The record shall be annotated each time a service is provided and be signed or initialed by the individual providing the service.

(5) Information contained in the record shall be appropriate in quality and quantity to meet the professional standards applicable to the provider and any additional standards for documentation found in these rules, other Division rules, and pertinent contracts.

(6) For AMH certified providers, in addition to meeting the requirements in this rule, clinical documentation for behavioral health services shall also comply with the requirements in OAR 309-019-0135 through OAR 309-019-0140, and clinical documentation standards for substance use disorder services shall comply with OAR 309-018-0140 through OAR 309-018-0150.

History

Statutory/Other Authority: ORS 413.042, 430.640, 430.705 & 430.715
Statutes/Other Implemented: ORS 414.025, 414.065 & 430.640
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0630 Medically Appropriate

(1) In addition to the definition of medically appropriate in OAR 410-120-0000 for behavioral health services, “medically appropriate” means the services and supports required to diagnose, stabilize, care for, and treat a behavioral health condition.

(2) The Division shall make payment for medically appropriate behavioral health services when the services or supports are:

(a) Rendered by a provider whose training, credentials, or license is appropriate to treat the identified condition and deliver the service;

(b) Based on the standards of evidence-based practice, and the services provided are appropriate and consistent with the diagnosis identified in the behavioral health assessment;

(c) Provided in accordance with an individualized service plan and appropriate to achieve the specific and measurable goals identified in the service plan;

(d) Not provided solely for the convenience of the recipient, the recipient’s family, or the provider of the services or supplies;

(e) Not provided solely for recreational purposes;

(f) Not provided solely for research and data collection;

(g) Not provided solely for the purpose of fulfilling a legal requirement placed on the recipient.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0640 Behavioral Health Services Fee Schedule

(1) The Division shall pay providers based on the Behavioral Health Services Fee Schedule (fee-for-service (FFS) payment rates for behavioral health services) posted on the Authority web site.

(2) Payment shall be made at each provider’s usual and customary charge or the Division’s published reimbursement upper payment limit, whichever is less, minus payments received or due from other payers. Payments to other specified providers shall be made according to other approved schedules.

(3) The Division’s maximum allowable rate-setting process uses a methodology that is based on the existing Medicaid fee schedule with adjustments for legislative changes and payment levels.

(4) Limitations contained in the Behavioral Health Services Fee Schedule, such as the maximum rate and the amount, duration, and scope of services provided, are subject to change at the discretion of the Division. Updates and changes are posted on the Behavioral Health Services Fee Schedule website at www.oregon.gov/OHA/HSD/OHP/Pages/Fee-Schedule.aspx.

(5) Payment shall be made for services listed in the Medicaid Behavioral Health Procedure Fee Schedule that are rendered to Medicaid-eligible individuals by a qualified provider during the period in which the provider is enrolled with the Division.

(6) For cost-reimbursed services, the provider shall maintain adequate records to thoroughly explain how the amounts reported on the cost statement were determined. The records shall be accurate and in sufficient detail to substantiate the data reported. Providers whose rates are paid based on a collective bargaining agreement are not exempt from this requirement.

(7) In accordance with 42 CFR § 405.506, a charge that exceeds the customary charge of the physician or other person who rendered the medical or other health service, or the prevailing charge in the locality, or an applicable lowest charge level may be found to be reasonable, but only where there are unusual circumstances, or medical complications requiring additional time, effort, or expense that support an additional charge, and only if it is acceptable medical or medical service practice in the locality to make an extra charge in such cases. The mere fact that the physician’s or other person’s customary charge is higher than prevailing would not justify a determination that it is reasonable.

(8) Payment by the Division does not limit the Authority or any state or federal oversight entity from reviewing or auditing a claim before or after the payment. Payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines that payment for the service was not provided in accordance with applicable Oregon Administrative Rules or the service does not meet the criteria for quality or medical appropriateness of the care.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 66-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0650 Prior Authorization

(1) Some services or items covered by the Division require authorization before the service may be provided. Services requiring prior authorization are published on the Medicaid Behavioral Health Services Fee Schedule.

(2) The Division shall authorize payment for the type of service or level of care that meets the recipient’s medical need and that has been adequately documented.

(3) The Division shall authorize only services that are medically appropriate and for which the required documentation has been supplied. The Division may request additional information from the provider to determine medical appropriateness.

(4) Documentation submitted when requesting prior authorization shall support the medical justification for the service. The authorization request shall contain:

(a) A cover sheet detailing relevant provider and recipient Medicaid numbers;

(b) Requested dates of service;

(d) Amount of service or units requested; and

(e) A behavioral health assessment and service plan meeting the requirements described in OAR 309-019-0135 through 0140; or

(f) Any additional clinical information supporting medical justification for the services requested;

(g) For substance use disorder services (SUD), the Division uses the American Society of Addiction Medicine (ASAM) Patient Placement Criteria second edition-revised (PPC-2R) to determine the appropriate level of SUD treatment of care. Providers shall use the ASAM;

(h) For Applied Behavior Analysis (ABA) services, the Division requires submission of the following:

(A) ABA services for the treatment of autism spectrum disorder shall have an evaluation as described in OAR 410-172-0770(1)(a–j) and a referral for treatment as described in OAR 410-172-0760(1) from one of the licensed practitioners described in OAR 410-172-0760(1)(a–d) who are, in addition, experienced in the diagnosis of autism spectrum disorder;

(B) ABA services for the treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder shall have an evaluation as described in OAR 410-172-0770(2) and a referral for treatment as described in OAR 410-172-0760(2) from a licensed practitioner, practicing within the scope of their license who has experience or training in the diagnosis and treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder;

(C) A treatment plan, including a functional behavior assessment, as needed, from a licensed health care professional as defined in ORS 676.802(2)(a–h), or by a behavior analyst or assistant behavior analyst licensed by the Oregon Behavior Analysis Regulatory Board, or by an individual holding a declaration of practice through the Oregon Behavior Analysis Regulatory Board as described in OAR 824-010-0005(10).

(i) For Intensive In-Home Behavioral Treatment Services (IIHBT), the Division requires submission of the following, in addition to the requirements described in 410-172-0650(4)(a-f), to the Division or the Division’s contractor:

(A) Initial prior authorization request may not exceed sixty (60) days, and authorization for continued services may be approved in 30-day increments. Each request shall include:

(i) Documentation by, at minimum, a Qualified Mental Health Professional, Licensed Medical Practitioner licensed in the state of Oregon, Licensed Clinical Practitioner, or psychologist licensed by the Oregon Board of Psychology, justifying IIBHT level of care;

(ii) Sufficient information and documentation to justify the presence of two or more primary mental health diagnoses that meets the medically necessary reason for services; and

(iii) Documentation displaying intensive behavioral health needs, that may include significant health and safety risks or concerns, impacting multiple life domains (school, home, community) as identified on a mental health assessment.

(B) A 30-day authorization for transition out of IIBHT services may be requested to support transition management for the treatment team, youth, and their family, and shall include an updated service plan describing ongoing maintenance of services and supports necessary for transition planning.

(j) Residential treatment services for children may require a letter of approval by a designated Quality Improvement Organization (QIO);

(k) Some services require additional approval or authorization by a physician, the Division, or designee. Services requiring additional approval are listed on the Behavioral Health Fee Schedule or described in this rule.

(5) The Division may not authorize services under the following circumstances:

(a) The request received by the Division was not complete;

(b) The provider did not hold the appropriate license, certificate, or credential at the time services were requested;

(d) The provider cannot produce appropriate documentation to support medical appropriateness, or the appropriate documentation was not submitted to the Division;

(e) The services requested are not in compliance with OAR 410-120-1260 through 1860;

(f) The provider is not currently enrolled in the Medicaid program or has not met requirements of OAR 410-120-1260, provider is currently suspended from the Medicaid program, or provider’s Division-assigned provider number is deactivated for any reason.

(6) Authorization for payment may be given for a past date of service if:

(a) On the date of service, the recipient was made retroactively eligible or was retroactively dis-enrolled from a CCO or PHP;

(b) The services provided meet all other criteria and Division administrative rules; and

(7) Any requests for authorization after 90 days from date of service require documentation from the provider demonstrating the specific reason why authorization could not have been obtained within 90 days of the date of service.

(8) Payment authorization is valid for the time-period specified on the authorization notice but may not exceed 12 months unless the recipient’s benefit package no longer covers the service, in which case the authorization shall terminate on the date coverage ends.

(9) Prior authorization of services shall be subject to periodic utilization review and retrospective review to ensure services meet the definition of medical appropriateness.

(10) Payments shall be made for the provision of active treatment services. If active treatment is not documented during any period in which the Division prior authorized the services, the Division may limit or cancel prior authorization or recoup the payments.

(11) If providers fail to comply with requests for documents for purposes of verifying medical appropriateness within the specified time-frames, the Division may deem the records non-existent, cancel prior authorization and recoup payments.

(12) In applying OAR 410-141-3061, OAR 410-172-0650 (5)(f), and OAR 410-172-0650(6), the Division may construe them as much as possible to be complementary. In the event that OAR 410-141-3061, OAR 410-172-0650(5)(f) and OAR 410-172-0650(6) may not be complementary, the Division shall apply the following order of precedence to guide its interpretation: OAR 410-120-0025, OAR 410-141-3061, OAR 410-172-0650(5)(f), and OAR 410-172-0650(6).

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 430.640, ORS 414.025, 414.065, 430.705 & 430.715
DMAP 59-2022, amend filed 06/21/2022, effective 06/21/2022
DMAP 49-2021, temporary amend filed 12/23/2021, effective 12/23/2021 through 06/20/2022
DMAP 37-2020, amend filed 07/23/2020, effective 07/23/2020
DMAP 14-2019, amend filed 05/23/2019, effective 06/27/2019
DMAP 109-2018, temporary amend filed 12/20/2018, effective 01/01/2019 through 06/29/2019
DMAP 12-2017, f. & cert. ef. 4-4-17
DMAP 60-2016(Temp), f. & cert. ef. 10-7-16 thru 4-4-17
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0660 Rehabilitative Behavioral Health Services

(1) Rehabilitative Behavioral Health Services means the medical or remedial services recommended by a licensed medical practitioner or other licensed Practitioner of the Healing Arts as defined in OAR 410-120-0000 for individuals experiencing impaired functioning associated with the symptoms of a mental disorder or substance use disorder and are provided for the purpose of reducing the impairment and restoring functioning to the highest degree possible.

(2) Remedial rehabilitative behavioral health services shall be recommended by a physician licensed by the Oregon Medical Board or a licensed Practitioner of the Healing Arts as defined in OAR 410-120-0000 and section 5(a and b) of this rule.

(3) Rehabilitative behavioral health services that include the provision of medical services shall be recommended by and provided under ongoing oversight of a licensed medical practitioner as described in section 4(a or b) of this rule.

(4) Rendering providers of rehabilitative behavioral health services shall meet one of the following qualifications:

(a) Physician or Physician Associate licensed by the Oregon Medical Board;

(b) Advanced Practice Registered Nurse, including Clinical Nurse Specialist and Nurse Practitioner licensed by the Oregon Board of Nursing;

(d) Licensed Professional Counselor (LPC) or Licensed Marriage and Family Therapist (LMFT) licensed by the Oregon Board of Licensed Professional Counselors and Therapists;

(e) Licensed Clinical Social Worker (LCSW) licensed by the Oregon Board of Licensed Social Workers;

(f) Licensed Master’s Social Worker (LMSW) licensed by the Oregon Board of Licensed Social Workers as described in OAR 877-015-0105;

(g) Licensed Psychologist Associate granted independent status by the Oregon Boards of Psychology as described in OAR 858-010-0039;

(h) Licensed Occupational Therapist licensed by the Oregon Occupational Therapy Licensing Board;

(i) Organizational Provider as defined in ORS 430.637 that holds a current Certificate of Approval for outpatient treatment services issued by OHA’s Behavioral Health Division (BHD) as described in OAR chapter 309, Behavioral Health Services, division 008.

(5) Effective July 1, 2027: The Associates licensed or registered by one of the licensing boards identified in section (b) of this section (5) may be rendering rehabilitative behavioral health services if the Associate:

(a) Is employed by or contracted with an organization that is certified by OHA in accordance OAR chapter 309, Behavioral Health Services, division 008 and meet the qualifications for any one of the following provider types:

(b) Has been issued a certificate of approval (COA) by the OHA in accordance with OAR chapter 309, Behavioral Health Services, division 008, and meet the qualifications for any one of the following provider types:

(A) Professional Counselor Associates registered with the Oregon Board of Licensed Professional Counselors and Therapists as described in OAR chapter 833, Mental Health Regulatory Agency, division 50;

(B) Marriage and Family Therapist Associate registered with the Oregon Board of Licensed Professional Counselors and Therapists as described in OAR chapter 833, Mental Health Regulatory Agency, division 50; or

(C) Certified Clinical Social Work Associate issued by the Oregon Board of Licensed Social Workers as described in OAR chapter 877, Board of Licensed Social Workers, division 20.

(c) Nothing in this section shall be read to require a COA when one of the exceptions identified in section (10) of this rule is met.

(6) Mental Health Interns may provide rehabilitative behavioral health services when the Intern:

(a) Is under the supervision of one of the licensed provider types identified in section (4) (c-e) of this rule; and

(b) Has submitted a collaborative agreement between school and provider.

(7) The following providers are required to be employed by a provider organization certified by OHA’s Behavioral Health Division:

(a) Qualified mental health professional or a qualified mental health practitioner (QMHP) as defined in OAR chapter 309, Behavioral Health Services, division  019;

(b) Qualified mental health associate (QMHA) as defined in OAR chapter 309, Behavioral Health Services, division 019;

(c)  Peer-Support Specialist (PSS), Peer Wellness Specialist (PSW),and Youth Support Specialist (YSS) or Family Support Specialist (FSS), as each are defined in OAR Chapter 950, Equity and Inclusion Division, division 060 or Certified Recovery Mentor (CRM) as defined in OAR 309-083-0010  chapter 950, Equity and Inclusion Division, division 060;

(d) Certified alcohol and drug counselors (CADC) certified by the Mental Health & Addiction Certification Board of Oregon (MHACBO);

(e) Certified gambling addiction counselors (CGAC) certified by MHACBO; and

(f) Effective 7/1/2027 Board Registered Behavioral Health Associates, unless exempt under section (10) of this rule.

(8) In addition to meeting the provider requirements described in this rule, providers of Assertive Community Treatment (ACT) services shall be certified as a fidelity ACT team by the BHD as described in OAR chapter 309, Behavioral Health Services, division 019.

(9) In addition to meeting the provider requirements described in this rule, providers of Individual Placement and Supports (IPS) Supported Employment Services as defined in OAR 309-019-0270 must be certified as a fidelity program by the BHD or its designee as described in OAR chapter 309, Behavioral Health Services, division 019.

(10) Notwithstanding any other provisions of this rule, a COA is not required for billing Medicaid when provider described in section (5) works in the following settings:

(a) Clinics recognized by Health Resource Service Administration (HRSA) as federally supported safety-net clinics. These federally supported safety net clinics may include support from HRSA itself as well as other federal regulatory agencies or programs, including, without limitation, Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) as defined in OAR 410-147-0000.

(b) An Indian Health Care Provider, as defined in OAR 410-120-0000;

(d) Higher Education settings that offer degrees, certificates, or workforce training and which may include two-year community colleges, four-year public universities, and career or trades schools;

(e) Education Agencies (EA) as defined in OAR 410-133-0040, when:

(A) Services are provided in compliance with School-Based Health Services (SBHS) as described OAR chapter 410, Medical Assistance Programs, division 133; and

(B) The EA employs a supervisory-level, as defined in OAR 410-133-0040, behavioral health provider to provide direct supervision for employed board-registered behavioral health associates.

(f) Psychologist Residents as described in ORS 675.030(2);

(g) Licensed Psychologist Associate under continued supervision as described in Oregon Laws 2021, chapter 211, section 2.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 29-2026, amend filed 06/30/2026, effective 07/01/2026
DMAP 23-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 104-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 59-2016, f. 10-4-16, cert. ef. 10-11-16
DMAP 50-2016(Temp), f. 8-1-16, cert. ef. 8-3-16 thru 10-11-16
DMAP 16-2016(Temp), f. & cert. ef. 4-15-16 thru 10-11-16
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0670 Substance Use Disorder Treatment Services

(1) Substance Use Disorder (SUD) treatment services shall be culturally and linguistically responsive and include; screening, assessment, individual counseling, group counseling, individual family and/or couple counseling, group family and/or couple counseling, care coordination, medication assisted treatment, medication management, collection and handling of specimens for substance analysis, interpretation services, acupuncture, withdrawal management, opioid treatment, crisis stabilization services as described in OAR chapter 309 division 023, community integration services, housing support services and employment supports services as described in OAR chapter 309 division 019, case management or targeted case management and peer delivered services.

(2) Providers seeking reimbursement for the provision of SUD services within the scope of their practice under Oregon Revised Statute (ORS) chapter 430 shall meet one of the following qualifications:

(a) Maintain a SUD Certification of Approval (COA) issued by the Division as described in OAR chapter 309 division 008;

(b) Any facility that meets the definition of a residential treatment facility for substance-dependent individuals under ORS 443.400 or withdrawal management programs also known as a detoxification center as defined in ORS 430.306 shall have an SUD certification issued by the Division as described in OAR chapter 415, division 012;

(d) Substance use withdrawal management programs also known as detoxification centers shall meet the standards described in OAR chapter 309 division 008;

(e) Physician or Physician Associate licensed to practice in the State of Oregon, as described in OAR chapter 847 division 065;

(f) Advanced Practice Nurse including Clinical Nurse Specialist and Certified Nurse Practitioner licensed to practice in the State of Oregon by the Oregon Board of Nursing, as described in OAR chapter 851 division 053;

(g) Professional Counselor or Marriage and Family Therapist licensed to practice in the State of Oregon by the Oregon Board of Licensed Professional Counselors and Therapists, as described in chapter 833 division 030 to 040;

(h) Clinical Social Worker licensed to practice in the State of Oregon by the Oregon Board of Licensed Social Workers, as described in OAR chapter 877 division 020;

(i) Psychologist licensed to practice in the Oregon Board of Psychology as described in OAR chapter 858 division 010;

(j) Licensed Psychologist Associate granted independent status as described in OAR chapter 858 division 010;

(k) Licensed Master Social Worker licensed to practice in the State of Oregon by the Oregon Board of Licensed Social Workers as described in OAR chapter 877 divisions 015 and 020;

(L) Acupuncturist licensed to practice in the State of Oregon by the Oregon Medical Board as described in OAR chapter 847 division 070;

(m) “Specialty Program” means a licensed Residential Substance Use Disorder treatment program that focuses on providing treatment to specialized populations. Treatment programming and planning shall be specialized to the population and individual being served.

(3) Board registered intern providers shall be supervised by a paid provider described in section (2)(g-i) of this rule under an active board approved plan of practice and supervision and meet one of the following qualifications:

(a) Psychologist Associate Residents as described in OAR chapter 858 division 010 0037;

(b) Licensed Psychologist Associate under continued supervision as described in OAR chapter 858 division 010;

(c) Licensed Professional Counselor intern or Marriage and Family Therapist intern registered with the Oregon Board of Licensed Professional Counselors and Therapists as described in OAR chapter 833 division 050;

(d) Certificate of Clinical Social Work Associate issued by the Oregon Board of Licensed Social Workers as described in OAR chapter 877 division 020;

(e) Registered Bachelor of Social Work issued by the Oregon Board of Licensed Social Workers as described in OAR chapter 877 division 020.

(4) Providers exempt from licensure or registration per ORS 675.523(3) shall be employed by or contracted with an entity that is certified or licensed by the State of Oregon under OAR chapter 309 division 008 to provide mental health treatment or addiction services, provided that the person is practicing within the lawful scope of the person’s employment or contract.

(5) Providers seeking reimbursement for the provision of SUD Residential Specialty Program shall ensure individuals accessing services meet one of the following qualifications:

(a) Pregnant and/or parenting with dependent children. Such programs shall ensure:

(A) Individuals receiving services:

(i) Are pregnant, or;

(ii) Have their infant(s) and/or toddler(s)/young child(ren) reside with them in the treatment facility, or;

(iii) Are complying with an ODHS plan to regain custody of their child(ern) and have a recommendation from the DHS caseworker to attend a parenting program;

(B) Day Care be provided for every infant and/or toddler/-young child; and

(D) Family therapy is made available to all individuals; and

(E) Screening and counseling services are made available for each child as defined under OAR chapter 309 division 018; and

(F) School-aged children attend school regularly and are provided assistance with their schoolwork or a tutor or other support as identified by the school, parent, ODHS, EPSDT Service Provider or program; and

(G) Transportation is arranged or provided for medical, dental, outpatient behavioral health, educational and other necessities; and

(H) Peer-delivered services are offered when medically necessary and appropriate and identified in an individual’s treatment plan.

(b) Culturally and Linguistically Specific Services shall be designed to meet the unique service needs of a specific culture and provide services designed to meet the needs of the majority of individuals representing that culture.

(A) Types of culturally specific programs include:

(i) LGBTQIA2S+;

(ii) Specific cultural, racial and/or ethnic group(s);

(iii) Tribal members;

(iv) Veterans.

(B) Culturally and Linguistically Specific Services shall:

(i) Be approved and designated as a culturally specific programs on license and meet all criteria in OAR 309 018 0170;

(ii) Provide Peer-delivered services as outlined in OAR 950 Chapter 060.

(6) Providers seeking reimbursement for Community Transition Services for SUD Residential Programs shall meet the following qualifications:

(a) Not exceed $5,000 per member per lifetime; and

(b) Enable individuals to obtain an independent, community-based living setting;

(7) Allowable expenses pursuant to (6) (b) of this rule may include:

(A) Security deposits required to obtain a lease on an apartment or home;

(B) Essential household furnishings required to occupy and use a community domicile including furniture, window coverings, food preparation items, and bed/bath linens;

(C) Set-up fees or deposits for utility or service access, including landline phone or cellular phone service, electricity, heating, and water;

(D) Services necessary for the individual’s health and safety such as pest eradication and one-time cleaning prior to occupancy;

(E) Moving expenses;

(F) Necessary home accessibility adaptations;

(G) Activities to assess need, arrange for, and procure needed resources.

(8) Services not included in the Community Integration Services Housing Benefit:

(A) Payment of rent, mortgage, or other room and board costs;

(B) Capital costs related to the development or modification of housing;

(D) Food Expenses

(E) Household Appliances

(F) Items, goods or services intended for purely diversional, leisure, or recreation purposes;

(G) Duplicative services from other state or federal programs;

(H) Services to individuals in a correctional institution or an Institution of Mental Disease (IMD) (other than services that meet the exception to the IMD exclusion);

(9) Community Transition Services eligible for reimbursement shall be furnished only to the extent that they are reasonable and necessary as determined through the service plan development process, clearly identified in the service plan and only when the person is unable to meet such expense or when the services cannot be obtained from other sources.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 430.640, 414.025, 414.065, 430.705 & 430.715
DMAP 24-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 77-2023, amend filed 09/19/2023, effective 09/19/2023
DMAP 25-2023, temporary amend filed 04/05/2023, effective 04/07/2023 through 10/02/2023
DMAP 52-2021, amend filed 12/28/2021, effective 01/01/2022
DMAP 59-2016, f. 10-4-16, cert. ef. 10-11-16
DMAP 50-2016(Temp), f. 8-1-16, cert. ef. 8-3-16 thru 10-11-16
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0680 Residential Treatment Services for Children

(1) Paid providers of children’s psychiatric residential treatment services shall:

(a) Hold a Certificate of Approval Pursuant to OAR 309-012-0130 through 309-012-0220 from AMH; and

(b) Be accredited as a psychiatric residential treatment facility for children under age 18 by JCAHO, CARF, or any other accrediting organization with comparable standards that is recognized by the State of Oregon;

(2) Residential Treatment Services for Children shall provide a program consistent with standards set by JCAHO, CARF, or any other accrediting organization with comparable standards that is recognized by the state.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0690 Admission Procedure for Psychiatric Residential Treatment Services for Children

(1) Admission procedures for children eligible for Medicaid shall be reviewed through an independent psychiatric review process established by the Division to certify the need for services.

(2) Referral to psychiatric residential treatment services shall be because:

(a) Medically appropriate treatment of the child’s psychiatric condition requires services on a 24-hour residential basis under the direction of a Licensed Medical Practitioner (LMP) as defined in OAR 309-019-0105; and

(b) The services can reasonably be expected to improve the child’s condition or prevent further regression so that the services will no longer be needed.

(3) The referring source shall make available to the third-party reviewer for the Certificate of Need (CON) process the following information about the referred child:

(a) A written psychological or psychiatric evaluation or progress note from a face-to-face service completed by a treating, LMP within the previous 60 days that recommends treatment in a 24-hour facility under the direction of an LMP;

(b) A written psychosocial history;

(c) Other information from the referral source, other involved community agencies, and the family that are pertinent and appropriate;

(d) Identified care coordinator;

(e) Identified child and family team members;

(f) Service Coordination Plan:

(A) Intensive Care Coordination Plan as defined in OAR 410-141-3870; or

(B) Wraparound Plan of Care as defined in OAR 309-019-0326;

(g) Documentation regarding lower level of care outcomes or justification regarding how 24-hour psychiatric residential based treatment under the care of an LMP will meet the needs of the child; and

(h) For fee-for-service members, a letter from Community Mental Health Program (CMHP) approving the referral to this level of care.

(4) For emergency admissions, the CON shall be made by the team responsible for a plan of care as described in CFR 441.156 within 14 days from the date of admission.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 430.640, ORS 414.025, 414.065, 430.705 & 430.715
DMAP 31-2021, amend filed 07/16/2021, effective 07/26/2021
DMAP 4-2021, temporary amend filed 01/28/2021, effective 01/28/2021 through 07/25/2021
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0695 Intensive In-Home Behavioral Health Treatment Services for Youth (IIHBT)

(1) IIBHT services as described in OAR 309-019-0167 are intended as an outcome-based, transitional, and episodic period of care to provide service and supports in a natural environment that allows the individual and their family or caregivers to successfully remain or reintegrate into their home, in school and community.

(2) Participation in IIBHT services shall not be contingent upon successful completion of, or participation in, any other behavioral health treatment services.

(3) A Youth and Family shall not be required to participate in other services or supports, including Wraparound, to receive IIBHT.

(4) Youth may be eligible for IIBHT services in congregate care settings such as Behavioral Rehabilitation Services or Developmental Disability Group Homes.

(5) Youth are considered for IIBHT services without regard to race, ethnicity, gender, gender identity, gender presentation, sexual orientation, religion, creed, national origin, age, intellectual and/or developmental disability, IQ score, or physical disability.

(6) Prior to delivering any IIBHT service, IIBHT providers shall meet all qualifications, credentialing, or licensing standards and competencies described in OAR 309-019-0125, and OARs 950-060-0000 through 0160, and supervision requirements described in OAR 309-019-0130, OAR 309-019-0167, or as required by a licensing or certification board.

(7) To be eligible for IIBHT services, Youth ages zero through 20 years of age shall be determined by the Department of Human Services (Department) to meet Title XIX Medicaid eligibility criteria. The Department shall complete Title XIX Medicaid eligibility determinations according to OAR chapter 461, division 135, division 140, and division 155 rules, and OAR chapter 410 division 200 and division 120 rules.

(8) IIBHT services providers shall document services as described in OAR 410-120-1360 and OAR 410-0620. The Division may consider incomplete or insufficient documentation as required by OAR 410-172-0620 as non-existent records and recoup payments.

(9) IIBHT services providers shall retain clinical records for seven years and financial and other records for at least five years as described in 410-120-1360 Requirements for Financial, Clinical and Other Records. The Division may consider incomplete or insufficient documentation above as non-existent records and recoup payments.

(10) Qualified IIBHT services providers shall work with all providers and the youth and their family to provide transition planning as described in OAR 309-019-0167.

(11) The Division shall reimburse authorized IIBHT services that are medically appropriate as described in OAR 410-172-0630 and identified on the behavioral health fee schedule described in OAR 410-172-0640. Providers shall:

(a) Comply with Medicaid billing and payment rules described in OAR 410-120-1280 through 1340;

(b) Comply with prior authorization described in OAR 410-172-0650; and

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 430.640, ORS 414.025, 414.065, 430.705 & 430.715
DMAP 105-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 59-2022, amend filed 06/21/2022, effective 06/21/2022
DMAP 49-2021, temporary amend filed 12/23/2021, effective 12/23/2021 through 06/20/2022
DMAP 37-2020, adopt filed 07/23/2020, effective 07/23/2020

Or. Admin. R. 410-172-0705 Residential Rate Standardization

(1) Defined terms used in this rule but not defined in this section (1) have the meanings assigned to them in OAR 410-172-0005:

(a) “Acuity” means the level of residential service and support needs of an Individual experiencing functional deficits resulting from the symptoms of a diagnosed mental health condition or complicating medical, behavioral, or cognitive conditions;

(b) “Active Engagement” means service hours provided to individuals in a residential treatment program that support personal care and other habilitative services. Active engagement hours:

(A) May include providing habilitation services to an Individual or small groups;

(B) May occur before, during, or after the provision of ADL and IADL services for an Individual;

(D) May not include Psychosocial Rehabilitative Services (PRS).

(d) “Community Mental Health Program (CMHP)” means the organization of all services for individuals with mental or emotional disorders operated by, or contractually affiliated with, a local Mental Health Authority operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with the Authority. CMHPs are operated pursuant to OAR chapter 309, division 014;

(e) “CMS” means Centers for Medicare and Medicaid Services, the federal agency that administers Medicaid;

(f) “De Minimis Threshold” means the Office of Management and Budget (OMB) threshold of 10 percent for government program-related administrative costs;

(g) “Direct Care” means active engagement and supervision care for individuals in a residential treatment program;

(h) "Division” has the meaning provided in OAR 410-120-0000;

(i) “Functional Needs Assessment” means the comprehensive assessment or reassessment of the level of cognitive, physical, social and mental level of function that are or may be impacted by the Individual's diagnosed mental health condition in order to determine the Individual’s need for assistance with ADLs, IADLs and any associated care or treatment;

(j) “General Ledger” means the main accounting record of a company or organization;

(k) “Habilitation” or “Habilitative Services” means services designed to help an Individual attain or maintain their maximal level of independence and includes, but is not limited to, services provided in order to help an Individual acquire, retain, or improve skills in ADLs and IADLs, community survival skills, communication, self-help, socialization, and adaptive skills necessary to reside successfully in an Individual’s home or a community-based setting;

(l) “Home and Community Based Services (HCBS)” means services and supports that assist eligible individuals to remain in their home and community in accordance with the Code of Federal Regulations and Oregon Administrative Rules;

(m) “Independent and Qualified Agent (IQA)” means Oregon’s contracted vendor to perform functional needs assessments, person-centered service planning service coordination, transition coordination, service authorizations, and utilization review and management for individuals requesting or receiving 1915(i) Home and Community-Based Services, other Medicaid-funded behavioral health services, or state General Fund behavioral health services in an Individual’s home or a community-based setting.  The IQA conducts initial and annual 1915(i) HCBS State Plan Amendment eligibility determinations and redeterminations;

(n) “Instrumental Activities of Daily Living (IADL)” has the meaning provided in OAR 410-172-0600;

(o) “InterRAI” means a tool that has been developed for use in conducting Functional Needs Assessments of an Individual’s residential and behavioral health strengths and needs resulting from the symptoms of a diagnosed mental health condition. interRAI is the tool the Division has chosen to use, as approved by CMS in the Division’s state Medicaid Plan, to perform Functional Needs Assessments to determine eligibility for certain OHP Covered Mental Health Services as identified in this rule and as may be identified in other rules in OAR chapter 410, Division 172 and 173;

(p) “Level of Service Inventory (LSI)” means a tool that has been developed for use in conducting Functional Needs Assessment of residential and behavioral health strengths and needs resulting from the symptoms of a diagnosed mental health condition of an Individual;

(q) “Minimum Wage Regions” means geographic areas within Oregon in which fixed minimum hourly wage rates are set lower than the minimum wage rate as authorized by ORS 653.025;

(r) “Per Diem” means a payment made for each day an approved service is provided;

(s) “Performing Provider” means the direct care staff member actually providing a service to an Individual in a residential treatment program or separately billing a rehabilitative service to an Individual residing in a residential treatment program;

(t) "Person-Centered Service Plan (PCSP)” means the written description of the supports, desired outcomes, activities, and resources required for an Individual to achieve and maintain personal goals, health, and safety as described in OAR 411-004-0030 and developed in compliance with OAR 309-035-0185 through 0190. The PCSP must be completed and signed prior to the Individual receiving HCBS;

(u) “Personal Care” means assistance with the performance of ADLs and IADLs;

(v) “Program Capacity” means the number of beds licensed for residential treatment in a location;

(w) “Provider” means an individual, organizational provider, or CMHP that is enrolled by the Authority to provide personal care, other habilitative services, or PSR;

(x) “Psychosocial Rehabilitation (PSR) Services” means medical or remedial services recommended by a licensed physician or other licensed practitioner to reduce impairment to an Individual’s functioning associated with the symptoms of a mental disorder or to restore functioning to the highest degree possible;

(y) "Related Organization" means an entity that is under common ownership or control with, has control of, or is controlled by another organization. An entity is related if it has:

(A) Five percent or more ownership interest in the other organization; or

(B) Capacity derived from any financial or other relationship, whether exercised, to directly or indirectly influence or direct the activities of the other organization.

(z) "Residential Treatment Facility (RTF)" has the meaning provided in ORS 443.400(11) subject to exclusions as provided in ORS 443.405;

(aa) “Residential Treatment Home (RTH)” has the meaning provided in ORS 443.400(12) subject to exclusions as provided in ORS 443.405;

(bb) “Resident” means an Individual receiving treatment in a residential treatment program;

(cc) "Residential Services Costs” means costs associated with the provision of mental health services to individuals in residential treatment programs. Costs include direct and indirect services required to meet an Individual’s assessed needs for personal care and other habilitative services. Residential services costs do not include costs related to providing Psychosocial Rehabilitation (PSR) services;

(dd) “Residential Treatment Program” means a RTF, RTH, SRTF, and YAT facility that is licensed to provide mental health services but does not include adult foster homes as defined in OAR 309-040-0305;

(ee) “Retainer Payment” means a payment made for medical, behavioral, or psychiatric related temporary absences of 30 days or less from residential treatment programs for which the Division has provided prior authorization;

(ff) "Secure Residential Treatment Facility (SRTF)" has the meaning provided by OAR 309-035-0105(60);

(gg) "Standardized Rate" means a tiered payment rate for personal care and other habilitative services in a residential treatment program based on individual acuity, program capacity, and minimum wage regions;

(hh) "Start-Up Costs" means one-time costs incurred prior to the first resident being admitted;

(ii) “Supervision Hours” means the staff hours in a mental health residential treatment program for overseeing patients’ general activities throughout the day;

(jj) “Young Adult in Transition (YAT)” means an Individual who is developmentally transitioning into independenceand is of an age not less than 17 years, and not more than 25 years;

(kk) “Young Adult in Transition Facility (YAT Facility)” means a facility that is licensed by the Authority as set forth in OAR 309-019-0105 and provides services to a YAT.

(2) The Division applies a standardized rate for payment of personal care and other habilitative services provided in a residential treatment program.

(3) The Division develops standardized rates with a standardized rate methodology based on data from residential treatment programs that is collected and analyzed by an independent third party. The independent third party must collect and analyze provider general ledger cost data for the most recent full year of operation and must examine job classification and wage data.

(4) The analysis of the independent third party referred to in section (3) must:

(a) Align general ledger data;

(b) Evaluate the intensity of the staffing needs in terms of client acuity and level of need;

(d) Analyze program capacity to account for direct care and support costs related to the number of individuals in the home;

(e) Analyze geographic cost variations.

(5) The Division shall re-evaluate provider general ledger data at five-year increments.

(6) Subject to legislative funding and approval, the Division may trend the standardized rate to the annual Consumer Price Index (CPI) the state applies for the state’s minimum wage.

(7) Standardized rates for residential treatment programs are intended to pay for the following:

(a) Residential services costs for individual services and supports for residents of residential treatment programs including ADLs, IADLs, other habilitation services, and related indirect costs;

(b) Five percent vacancy rate for providers to use as a reserve.

(8) The following cost items may not be included in the calculation of standardized rates:

(a) Resident paid room and board;

(b) Psychosocial rehabilitation services;

(d) Costs incurred by a related organization that are not directly incurred for residential treatment program services;

(e) Administrative costs in excess of the de minimis threshold of ten percent of allowed costs; and

(f) Program start-up costs.

(9) The Division may use residential services costs in developing standardized rates as follows:

(a) On request of the Division, residential treatment programs must provide general ledger cost data that capture the most recent full year of operation;

(b) The Division may analyze provider costs by aggregating general ledger information from multiple residential treatment programs to identify relationships between direct care costs and other cost components such as employee benefits, training, transportation, and program-related facility costs;

(c) The Division may calculate the rates for each rate tier based on the amount and type of direct care hours, including active engagement hours and supervision hours.

(10) The maximum allowable rate the Division pays per client under the standardized rate methodology shall be according to rate tiers. The Division shall publish a table with specific rate amounts in the Behavioral Health Fee Schedule. Tiers shall be defined by but not limited to the following variables:

(a) Levels of need based on individual acuity;

(b) Program type and capacity; and

(11) The standardized rate tier is assigned to an Individual based upon an independent face-to-face assessment of an Individual’s needs for an Individual who is under 21 years of age as assessed by the LSI whose acuity is documented in a PCSP. The assessment classifies residents and prospective residents of residential treatment programs into acuity-based tiers of:

(a) Tier 1 for reserve capacity or an Individual whose acuity assessment significantly improves to no longer require the level of support provided in a residential setting, but the Individual has chosen to remain in the residential setting;

(b) Tier 2 for an Individual with an LSI of 40 or less;

(d) Tier 4 for an Individual with an LSI of 61+;

(12) Client individual acuity used to determine the standardized rate in the Division’s table shall be measured by an LSI or interRAI CMH, as defined in OAR 410-173-0005.

(13) The Division shall designate providers of assessments of client individual acuity, which may include:

(a) The Division staff qualified to perform an assessment;

(b) The Division’s contracted IQA; or

(14) The Division may authorize acuity reviews for the assignment of individuals to residential treatment rate tiers as follows:

(a) In preparation for a placement from the Oregon State Hospital (OSH) to a residential treatment program;

(b) In preparation for a residential treatment program placement from sources other than OSH;

(d) For residents with a significant change in acuity expected to last longer than 30 days.

(15) Providers may request the IQA perform an updated interRAI CMH or LSI assessment and reauthorization of services for an Individual at least annually or with a significant change in condition expected to last longer than 30 days.

(16) For individuals aged 21 and older, the Division will utilize the following interRAI CMH acuity scale scores to determine the rate paid for services using the standardized rate methodology in RTH, RTF and SRTF settings.

(a) Aggressive Behavior Scale;

(b) Cognitive Performance Scale;

(d) ADL Hierarchy;

(e) Instrumental Hierarchy; or

(f) Risk of Harm to Others.

(17) The Division may pay for services under the standardized rate methodology in RTH/RTF settings only when all the following requirements have been met with respect to the service:

(a) Tier 1 is a reserve capacity payment;

(b) Tier 2 must receive an average of three or more hours of active engagement daily;

(d) Tier 4 must receive an average of six or more hours of active engagement daily;

(e) Tier 5 must receive an average of seven or more hours of active engagement daily.

(18) The Division may pay for services under the standardized rate methodology in SRTF settings only when all the following requirements have been met with respect to the service:

(a) Tier 1 is a reserve capacity retainer payment;

(b) Tier 2 must receive an average of three or more hours of active engagement daily;

(d) Tier 4 must receive an average of seven or more hours of active engagement daily;

(e) A performing provider in residential treatment programs, including a provider of habilitation and PSR, must be enrolled with the Division and be identified in claiming services as the performing provider;

(f) A residential treatment program must have sufficient staff to meet active engagement and supervision hours as required by subsections (a), (b), (c), (d), and (e) of this section (18) during engagement hours. Refer to OAR 309-035-0135 for licensed residential treatment program staff requirements;

(g) A residential treatment program shall maintain adequate records to accurately substantiate all amounts reported in a general ledger and other cost statements;

(h) A residential treatment program must document at least daily the specific individual personal care and other habilitative services including skills building and other activities provided to enhance community integration, the Individual’s response to services provided, and planned activities related to the Individual’s assessment and PCSP;

(i) Upon request of the Division, a residential treatment program must provide monthly site-specific census data that includes individuals’ acuity assessment scores and any discharges or referrals and must report changes to submitted census data at least weekly.

(19) The Division’s payment of Medicaid allowable standardized rates for residential treatment program services including personal care and other habilitation services is considered payment in full and precludes any General Fund contract or other supplemental funding for Medicaid-allowable costs and services.

(20) Residential treatment program providers may not:

(a) Collect funds from any resident in excess of the room and board costs;

(b) Accept funds from any other source for services paid by Medicaid; or

(c) Submit claims for individual habilitation or PSR services that duplicate the per diem payment for residential personal care and other habilitation services.

(21) Standardized rates developed using Medicaid-allowable costs, policies and processes apply when the Division makes payment for services to non-OHP residents of residential treatment programs.

(22) Beginning July 1, 2019, PSR provided to residents of a residential treatment programs must be billed using individual services or unit billing, and the Division may not pay PSR using bundled per diem rates.

(23) The Division may pay a retainer payment to residential treatment programs:

(a) The Division may pay a retainer payment for residents in residential treatment programs for medical or psychiatric related temporary absences lasting 30 days or less;

(b) The Division may authorize and make a payment when an Individual is absent in order to be:

(A) Admitted to an acute care hospital;

(B) Admitted to a respite facility to avoid re-hospitalization or revocation of a conditional release order; or

(c) A retainer payment for temporary absences of 30 days or less from residential treatment programs requires the Division prior authorization. A prior authorization request must include:

(A) Requested dates of service;

(B) HCPCS or CPT procedure code requested;

(D) Additional clinical information supporting medical or psychiatric justification for the services requested, particularly the medical or psychiatric rationale for temporary absence.

(d) The retainer payment is payable at the Tier 1 rate.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 33-2026, amend filed 07/29/2026, effective 07/31/2026
DMAP 80-2025, amend filed 10/28/2025, effective 10/28/2025
DMAP 26-2019, adopt filed 06/26/2019, effective 06/28/2019
DMAP 110-2018, temporary adopt filed 12/20/2018, effective 01/01/2019 through 06/29/2019

Or. Admin. R. 410-172-0710 Residential Personal Care

(1) Personal care services shall be provided to residents of Division licensed residential treatment programs, as developmentally appropriate, as described in the resident’s person-centered service plan and residential plans of care.

(2) Personal care services are provided to individuals with behavioral health conditions that enable them to accomplish tasks that they would normally do for themselves if they did not have a behavioral health condition. Assistance may be in the form of hands-on assistance for the resident, supervising, cueing, or redirecting so that the individual performs the task on their own.

(3) Personal care services are provided in accordance with an individual’s assessment and the authorized plan for services made by a provider meeting the qualifications of a Qualified Mental Health Professional (QMHP) or Qualified Mental Health Associate (QMHA) as defined in OAR chapter 309 division 019.

(4) Personal care assistance relates to performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as defined in these rules.

(5) Personal care services may be provided on a continuing basis or on episodic occasion.

(a) For residential personal care services the Authority will pay the standardized rate in the behavioral health fee schedule in effect on the date of service.

(b) Residential personal care service are included in the per diem rate standardization described in OAR 410-172-0705.

(6) Paid providers of residential personal care services shall meet one of the following:

(a) Residential Treatment Homes (RTH), Residential Treatment Facilities (RTF), Secure Residential Treatment Facilities (SRTF) and Crisis-Respite Services programs as described in OAR chapter 309 division 35; or

(b) Adult Foster Home (AFH) as described in OAR chapter 309 division 40.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 430.640, 414.025, 414.065, 430.705 & 430.715
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 59-2016, f. 10-4-16, cert. ef. 10-11-16
DMAP 50-2016(Temp), f. 8-1-16, cert. ef. 8-3-16 thru 10-11-16
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0720 Prior Authorization and Re-Authorization for Residential Treatment

(1) The Division does not consider a request for a fixed episode of care or standardized length of stay to be medically appropriate. Requested length of stay shall be based on an assessment of individual medical necessity and the medical appropriateness of the proposed time for treatment.

(2) The need for residential treatment is outcome based. Specifically, residential treatment is intended to provide the services and supports in a structured environment that allows an Individual to successfully reintegrate into an independent community based living arrangement.

(3) Residential treatment is not intended to be used as a long-term substitute for lack of available supportive living environments in the community. Residential programs shall support the care coordination and transition management to ensure the individual is connected to appropriate and available supports for a smooth and planful discharge when adequate stabilization is achieved.

(4) Authority-licensed residential treatment programs that are not Secure Residential Treatment Facilities (SRTF) are reimbursed for the provision of specific services as follows:

(a) 1915(i) HCBS habilitative services as described in OAR 410-173-0015;

(b) Rehabilitative behavioral health services as described in OAR 410-172-0660;

(d) Habilitation or personal care services as described in OAR 410-172-0705.

(5) The Division shall authorize admission and continued stay in residential programs based on the medical appropriateness of the request and supporting clinical documentation.

(6) Prior authorization requests for admission and continued stays in residential service facilities shall be reviewed and documented by the Division or the Division’s Independent and Qualified Agent (IQA) to determine the medical necessity and medical appropriateness of each of the following:

(a) Recommended length of stay;

(b) Recommended plan of care;

(d) Any other Level of Care Determination required from OAR 410-172-0600(28).

(7) Prior authorization requests for admission and continued stay for a an SRTF shall be reviewed to confirm that the individual meets all the following criteria:

(a) The individual does not require 24-hour hospital care and treatment;

(b) The individual requires highly structured and secured environmental supports and supervision seven days per week, 24 hours per day in order to succeed in a program of habilitative and rehabilitative activities; and

(c) The Individual has, due to a mental illness, presented with one or more risks of harm set out in (A) - (D) of this subsection (c) within the last 90 days, which has been documented in the Individual’s clinical record(s) by either the Individual’s a treating physician, physician associate, or an advanced practice registered nurse who has been primarily responsible for treating the Individual:

(A) Clear intention or specific acts of bodily harm to others;

(B) Ideation and intent of either suicide or of self-harm posing significant risk of serious injury; which, if not in a secured environment, would allow for opportunity;

(C) Inability to care for basic needs that would, if not in a secured environment, result in worsening or development of a significant health condition;

(D) The individual’s mental health symptoms impact judgment and awareness to the degree that the individual may place themselves at risk of imminent harm; or

(E) Significant risk that the individual will not remain in a non-secured place of service to receive the services and supports necessary to stabilize the symptoms of a mental illness that pose a threat to the individual’s or others' safety and well-being.

(d) If an Individual has not been discharged from an SRTF upon expiration of 90 day authorization, the care team, which must include treating physician, physician associate, or an advanced practice registered nurse who has been primarily responsible for treating the Individual shall consider whether alternative courses of treatment within a less restrictive environment, including Assisted Outpatient Treatment (ORS 426.133), is medically necessary and appropriate.

(8) If the Division determines that a residential service, including those provided in a SRTFs, prior authorization request is not medically necessary and medically appropriate, the requesting provider shall be notified in writing of the basis for the decision and shall have ten business days to provide additional written documentation to support the medical necessity and medical appropriateness of the request for prior authorization.

(9) If, upon reconsideration, the Division upholds the denial of prior authorization, the requesting provider and individual shall be provided with a written notice of action that complies with OAR 410-120-1865, which requires the Division to include information on the Individual’s appeal and hearing rights.

(10) If the Division issues prior authorization and the provider is subsequently denied payment for claims submitted, the provider may appeal any final decision through the Division administrative appeals process as described in OAR 410-120-1560 through 410-120-1875.

(11) Upon denial of a prior authorization request for continued stay, the Division shall authorize payment for a period of time following expiration of the then-current prior authorized stay as is necessary to support a seamless transition of care for the Individual and make any arrangements necessitated by the denial decision. In no event shall the Division authorize a transition management period that exceeds 60 days. These authorizations will include the following:

(a) The Division shall provide written notice of a denial of a request for authorization of a continued stay in accordance with section (8) of this rule;

(b) The provider, the Individual and, as applicable, the Individual’s Guardian or Health Care Representative (as each of them is defined in OAR 410-173-0005), will be provided with notice of the denial and the up-to 60 day continued stay for transition purposes, in accordance with section (9) of this rule.

(12) The Division shall determine re-authorization and authorization of continued stays based upon documentation of at least one of the following:

(a) The Individual continues to meet all elements of medical appropriateness described in these rules;

(b) That the treatment provided is resulting in measurable clinical outcomes but that the Individual is not sufficiently stabilized or yet developed the skills necessary to support transition to any other residential setting; or

(c) The recipient develops new or worsening symptoms or behaviors that require continued stay in the current residential setting.

(13) Requests for continued stay based on these criteria in section (12) of this rule shall include documentation in the Individual’s clinical records of ongoing reassessment and necessary modification to the current treatment plan or residential plan of care.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 430.640, ORS 414.025, 414.065, 430.705 & 430.715
DMAP 33-2026, amend filed 07/29/2026, effective 07/31/2026
DMAP 31-2021, amend filed 07/16/2021, effective 07/26/2021
DMAP 4-2021, temporary amend filed 01/28/2021, effective 01/28/2021 through 07/25/2021
DMAP 8-2019, amend filed 03/27/2019, effective 04/01/2019
DMAP 94-2018, temporary amend filed 10/25/2018, effective 10/28/2018 through 04/25/2019
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0730 Payment Limitations for Behavioral Health Services

(1) Services shall be subject to periodic utilization review to determine medical appropriateness.

(2) If a review reveals that a recipient received less than active treatment, payment may not be allowed under these rules and prior authorization may be cancelled.

(3) The Division may make no payment for services if the Division or designee has determined the service is not medically appropriate.

(4) Residential treatment services are provided to Medicaid Title XIX eligible individuals in facilities with 16 or fewer beds. Payment is excluded for individuals in “institutions of mental diseases” (IMD) who are over age 18 and under age 65. IMDs are defined in 42 CFR 435.1010.

(5) For residential facilities, the Division shall pay for the day of admission but may not pay for the day of transfer or discharge.

(6) Medicaid may not reimburse costs associated with room and board for recipients residing in Authority licensed residential treatment programs.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 26-2019, amend filed 06/26/2019, effective 06/28/2019
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0760 Applied Behavior Analysis

(1) Applied Behavior Analysis (ABA) services for the treatment of autism spectrum disorder shall be recommended by a licensed practitioner who has experience in the diagnosis and treatment of autism spectrum disorder and holds at least one of the following educational degrees and valid license:

(a) Physician;

(b) Psychologist;

(d) Physician’s associate specializing in developmental medicine.

(2) ABA services for the treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder shall be recommended by a licensed practitioner, practicing within the scope of their license, who has experience or training in the diagnosis and treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder.

(3) Providers of ABA services eligible for direct payment shall hold the following license, registration, or declaration of practice:

(a) Licensed Behavior Analyst as described in OAR 824-030-0010;

(b) Licensed health care professional as defined in 2015 Oregon Laws Chapter 674, section 1 who is registered with the Oregon Behavior Analyst Certification Board as described in ORS 676.802(2)(a–h);

(c) Individual holding a declaration of practice through the Oregon Behavior Analysis Regulatory Board as described in OAR 824-010-0005(10).

(4) The following ABA service providers are not eligible for direct payment:

(a) Assistant Behavior Analyst licensed by the Oregon Behavior Analysis Regulatory Board as described in OAR 824-030-0020;

(b) Behavior Analysis Interventionists registered by the Oregon Behavior Analysis Regulatory Board as described in OAR 824-030-0040.

(5) Initial and ongoing six month assessments of core skills by ABA licensed providers for the purpose of measuring progress achieved during ABA treatment must:

(a) Use standardized, validated and reliable assessment tools that allow for tracking an individual’s progress over time;

(b) Result in a treatment plan with specific, observable, and quantifiable goals that are relatable to identified skills deficits.

(6) Initial and ongoing six month assessments of behavior that is considered to have an adverse impact on the individual’s development or is harmful to the individual or to others must have treatment goals that are specific, observable, and quantifiable and must relate to identified behavioral concerns.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 25-2025, minor correction filed 01/09/2025, effective 01/09/2025
DMAP 12-2017, f. & cert. ef. 4-4-17
DMAP 60-2016(Temp), f. & cert. ef. 10-7-16 thru 4-4-17
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0770 Individual Eligibility for Applied Behavioral Analysis Treatment

(1) Prior to receiving services, individuals receiving ABA services for the treatment of autism spectrum disorder (ASD) shall have an evaluation by a licensed practitioner, described in OAR 410-172-0760(1)(a–d), experienced in the diagnosis and treatment of autism using the current DSM criteria that includes:

(a) A diagnosis of an ASD listed on the ASD line of the Health Evidence Review Commission’s (HERC) Prioritized List;

(b) Documentation of and results from a standardized, validated tool, such as the Autism Diagnostic Observation Schedule (ADOS), that has been used to substantiate the autism disorder;

(c) Documentation of individual core features of autism as identified through a review of ASD diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM 5);

(d) Documentation that a parent or caregiver has been interviewed;

(e) Documentation that there was a review of relevant medical records;

(f) Documentation that the practitioner was able to observe the individual directly;

(g) Documentation of developmental status using validated assessments or a combination of such assessments, such as the Vineland. This information may be provided by a licensed ABA provider;

(h) Documentation of a comprehensive medical exam. A physical exam from the most recent well child care visit may be submitted if within one year for children aged 1-6, or within two years for children 6-18. The physical exam must be completed before starting ABA but may not be allowed to delay or interrupt ABA services;

(i) Documentation that an audiology or hearing test has been performed within one year for children aged 2 through 5, or within two years for children aged 6 through 18. The audiology or hearing test must be completed before starting ABA but may not be allowed to delay or interrupt ABA services;

(A) Newborn assessment is not sufficient after the age of 24 months;

(B) Hearing tests from primary care offices and schools are sufficient if there are no concerns regarding hearing;

(j) Any other documentation, if available, that would substantiate the diagnosis of autism or stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder including but not limited to the following:

(A) Notes from well-child visits or other medical professionals;

(B) Results from any additional assessments including but not limited to IQ, achievement tests, speech and language tests, and assessments of adaptive functioning.

(k) A referral for ABA treatment with or without specification of hours or intensity that shall include:

(A) A diagnosis of ASD or stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder;

(B) A copy of the evaluation described in 410-172-0770(1);

(2) Prior to receiving services, individuals receiving ABA for the treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder shall have an evaluation by a licensed practitioner, practicing within their scope of practice, who has training or experience in the diagnosis and treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder that includes results from a questionnaire or observations that have been used to substantiate the diagnosis.

(3) Prior authorization for intensive and less intensive interventions must be based on an individualized determination of medical appropriateness for each individual and relevant guideline notes from the HERC Prioritized List at the initiation and continuation of ABA services. Services in excess of the HERC Prioritized List coverage guidance or guideline notes shall be provided when medically appropriate for a particular individual, including individuals age 13 and older. Relevant factors to consider when making a prior authorization determination include but are not limited to the following:

(a) Severity;

(b) Depth and breadth of previous treatment;

(c) How recently the diagnosis has been made. For example, if the diagnosis has been made after the child turned 13, intensive treatment shall be considered;

(d) Comorbidities such as psychiatric disorders, developmental delays, and intellectual disability may make it harder to treat ASD and may require more intensity of treatment to be effective;

(e) Factors that would be contrary to the efficacy of ABA or increased intensity of ABA services.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 12-2017, f. & cert. ef. 4-4-17
DMAP 60-2016(Temp), f. & cert. ef. 10-7-16 thru 4-4-17
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0774 Temporary rule language in effect until 02/15/2027. State Plan Personal Care Program: Purpose and Scope

(1) The State Plan Personal Care (SPPC) program provides state plan personal care services support to individuals in accordance with the State Medicaid Plan. The SPPC program is intended to enhance an individual’s independence, empowerment, dignity and human potential through the provision of flexible, efficient and suitable personal care services to eligible adults and children. The SPPC program is not intended to replace an individual's own personal abilities or natural and other supports.

(2) The rules applicable to the SPPC program are set out in OARs 410-172-0774 through 410-172-0845.

(3) There are two types of providers authorized to provide services directly to individuals who have been approved to receive services through the SPPC program:

(a) Direct support worker (DSW), who is employed by an Agency with Choice (AWC) and is defined in 410-172-0776.

(b) Personal care attendant (PCA) who is not employed by an Agency with Choice (AWC) as defined in OAR 410-172-0776.

(c) Unless a rule or a specific section in a rule expressly states that the rule or section applies to one type of authorized provider only, the rule or section must be interpreted to apply to both DSWs and PCAs.

(4) When a provision in OARs 410-172-0600, 410-172-0774 through 410-172-0845 references another rule in a different OAR chapter and division or in a different division within OAR chapter 410, the rule that must be given effect is the version that is or was in effect as of August 10, 2026.

(5) These rules are not intended to conflict with or supersede any applicable collective bargaining agreement governing homecare workers, personal support workers, or personal care attendants. In the event of a conflict, applicable state or federal law and the terms of the collective bargaining agreement shall control.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & ORS 414.025
DMAP 36-2026, temporary adopt filed 08/20/2026, effective 08/20/2026 through 02/15/2027

Or. Admin. R. 410-172-0776 Temporary rule language in effect until 02/15/2027. State Plan Personal Care Program Definitions

In addition to the defined words in OAR 410-172-0600, the definitions in this rule apply to OARs 410-172-0775 through OAR 410-172-0840, which apply to SPPC Program. If a word defined in this rule conflicts with a word defined in 410-172-0600, the word defined in this rule will apply.

(1) “Agency with Choice” means an organization licensed by the Oregon Health Authority in accordance with OAR chapter 309, division 045 that provides the Agency with Choice services.

(2) “Agency with Choice Services” means personal care and other related services provided to an individual by an Agency with Choice in accordance with OARs 410-172-0776 through 410-172-0845 and OAR chapter 309, division 45.

(3) "Assistance” means help needed by and provided to an individual in performing Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs). When provided to an individual, assistance includes hands-on assistance, cueing, and supervision. Supervision includes monitoring, set-up, reassurance, and stand-by.

(4) "Assistive Devices" means any category of durable medical equipment, mechanical apparatus, electrical appliance, or instrument of technology used to assist and enhance an individual's independence in performing any task described in OAR 410-172-0780.

(5) "Assistive Supports" means the aid of service animals, general household items, or furniture used to assist and enhance an individual’s independence in performing any task described in OAR 410-172-0780.

(6) "Background Check" means a criminal history check and abuse check as described in OAR chapter 407 division, 007, including criminal records as adopted in OAR chapter 943, division 007.

(7) “Care Coordinator” means the person responsible for referring individuals to qualified providers that can provide authorized personal care services and coordinating the care an individual receives.

(8) "Collective Bargaining Agreement (CBA)" means the ratified Collective Bargaining Agreement between the Home Care Commission and the Service Employees International Union, Local 503. The Collective Bargaining Agreement is maintained on the Department's website:https://www.oregon.gov/odhs/providers-partners/homecare-workforce/Pages/default.aspx). Printed copies may be obtained by writing the Oregon Department of Human Services, Aging and People with Disabilities, ATTN: Rules Coordinator, 500 Summer Street NE, E-2, Salem, Oregon 97301.

(9) “Consumer-Employer" means an individual, or the individual’s authorized representative, who employs a personal care attendant and performs employer responsibilities under these rules. Individuals who receive in-home services from a direct support worker through an Agency with Choice are not consumer-employers.

(10) "Cost Effective" means being responsible and accountable with Authority resources. This is accomplished by offering less costly alternatives while providing choices that adequately meet an individual’s service needs. Those choices consist of all available service options, the utilization of assistive devices or assistive supports, natural supports, architectural modifications, and alternative service resources. Less costly alternatives may include resources not paid for by the Authority.

(11) "Developmental Disability" as defined in OAR 411-320-0020 and described in OAR 411-320-0080.

(12) “Direct Contact” means services provided by a service coordinator through direct communication with an individual or their authorized representative via phone, email or face-to-face contact, as directed by the individual, for the purposes of care coordination and service-plan monitoring.

(13) “Direct Support Worker (DSW)” means a person employed by an Agency with Choice who assists individuals with ADLs and IADLs and health related tasks identified in the individual’s person-centered service plan. A direct support worker is different than “personal care attendant,” which is defined in OAR 309-045-0310.

(14) “Duty to Maintain Consumer-Employer Confidentiality” means a personal care attendant will not disclose personally identifiable information about a consumer-employer unless otherwise authorized by law.

(15) “Electronic Visit Verification (EVV)” means a system that verifies, in accordance with 42 U.S.C 1396b(I), personal care services provided to an individual under the state plan personal care program, as follows:

(a) Type of services;

(b) The individual who received the service;

(d) The location of service delivery;

(e) The name of the personal care attendant providing the service; and

(f) The time the services began and ended.

(16) "Exerts Undue Influence" means a personal care attendant assumes or attempts to assume control of an individual’s decision-making, finances, home, property, medication, social interaction or ability to communicate, through coercion or other non-persuasive, threatening means. Exertion of undue influence may exist whether or not an individual willfully allows the personal care attendant to assume such control.

(17) "Fiscal Improprieties" means a personal care attendant committed financial misconduct involving an individual's money, property, or benefits.

(a) Fiscal improprieties include, but are not limited to:

(A) Financial exploitation, as defined in ORS 430.735 and described in OAR 411-020-0002, including:

(i) Wrongfully taking, by means including, but not limited to, deceit, trickery, subterfuge, coercion, harassment, duress, fraud, or undue influence, the assets, funds, property, or medications belonging to or intended for the use of an adult;

(ii) Alarming an adult by conveying a threat to wrongfully take or appropriate money or property of the adult if the adult reasonably believes the threat conveyed may be carried out;

(iii) Misappropriating or misusing any money from any account held jointly or singly by an adult;

(iv) Failing to use income or assets of an adult for the benefit, support, and maintenance of the adult; or

(v) The taking, borrowing, or accepting of assets, funds, property, or medications from an adult residing in a facility by an employee of the facility, unless the adult and employee are related and the action described in this paragraph does not constitute a wrongful taking as described in (i).

(B) Improper financial transactions with an individual, including but not limited to:

(i) Borrowing money, property, or belongings from an individual;

(ii) Accepting or receiving funds, or services purchased for the personal care attendant by the individual.

(i) Forging an individual’s signature;

(ii) Falsifying payment records, including submitting incorrect start and end times of work;

(iii) Submitting payment for days that were not worked; or

(iv) Claiming to deliver services to an individual during a time also claimed for travel between worksites;

(v) Working or claiming to work hours not authorized on a consumer-employer's person-centered service plan or working or claiming hours over the maximum weekly hours permitted under the Collective Bargaining Agreement;

(vi) Claiming hours worked for an individual while taking time off or when a relief care provider, as described in the CBA, is paid for providing services;

(vii) Requesting or demanding payment for services from either the Authority or the individual in excess of the amount paid following the submission and processing of a properly completed claim;

(viii) One or more intentional acts of dishonesty for purposes of unearned financial gain; or

(ix) Creating an overpayment whether intentionally or unintentionally and not paying it back within six months.

(b) Fiscal Improprieties do not include the exchange of money, gifts, or property between a personal care attendant and an individual with whom the personal care attendant is related unless an allegation of financial exploitation, as defined in OAR chapter 411-020-0002 or ORS 430.735, has been substantiated based on an adult protective services investigation.

(18) “Information and Referral” means providing referral and related activities, such as assisting the individual to schedule appointments, obtain needed services, and connect the individual with medical, social, and educational providers or other programs and services that can provide services to address the identified needs of the individual.

(19) "Mandatory Abuse Reporter" means any public or private official, including personal care attendants who are required by state abuse statutes, to report alleged abuse. Rules related to Mandatory Reporter for Agencies with Choice, and direct support workers are referenced in OAR chapter 309 division 045.

(20) “Notice of Action” means a written document that is sent by the Authority or its designee to the individual and as applicable, the individual’s referring provider or Authorized Representative, that outlines why an individual’s request for personal care services has been denied in full or in part and complies with the requirements set out in OAR 410-120-1865.

(21) “Personal Care Attendant (PCA)” means a type of personal support worker, as defined in ORS 410.600, who is hired to provide personal care services to an individual with a behavioral health condition or disability who resides in their own Home, Family Home or community setting. A PCA can be hired by the individual, a parent of a child, or the individual’s legal or authorized representative.

(22) "Provider" or "Qualified Provider" for the purposes of these rules means:

(a) A personal care attendant who is an enrolled provider with the Authority, meets the training and education and qualifications in OAR Chapter 418 Division 020, and performs personal care services for individuals not residing in a facility; or

(b) An Agency with Choice that is an enrolled provider with the Authority, meets the qualifications in OAR chapter 309 division 045 and employs direct support workers who perform personal care services for individuals not residing in a facility. An Agency with Choice assumes co-employer responsibilities with the individual receiving personal care services. The co-employer responsibilities include worker training, payroll, and compliance with Electronic Visit Verification requirements as described in chapter 309 division 045.

(23) “Person-Centered Service Plan” means the written document prepared by the IQA service coordinator that details the supports, desired outcomes, activities, and resources required for an individual to achieve and maintain personal goals, health, and safety as described in OAR 410-173-0025.

(24) "Provider Number" means a unique identifying number issued to an Agency with Choice and each personal care attendant who is enrolled with the Authority as a Medicaid provider.

(25) "Service Authorization" means the written documentation issued by the Authority to the individual informing them of the services approved in the individuals’ service plan. Sometimes, a service authorization may also be a Notice of Action as defined in this rule. A service authorization identifies:

(a) The qualified provider who is authorized to provide personal care services to the individual;

(b) The date the individual is authorized to begin receiving personal care services from the qualified provider; and

(d) The maximum hours an individual is authorized to receive personal care services during a service period.

(26) "Service Coordination” means the functions performed by a service coordinator and includes determining service eligibility for home and community-based services, including personal care services, based on program criteria, conducting a needs-based assessment for services and developing a person-centered service plan.

(27) “Service Coordinator” means a qualified mental health practitioner employed by the Authority’s IQA who:

(a) Determines eligibility for services in accordance with program requirements;

(b) Conducts needs-based assessment to identify individual’s functional needs for services;

(b) Develops person-centered service plan with individuals based on their assessed needs;

(c) Informs individuals of available service options and assists individuals in identifying appropriate services and supports based on assessed needs and the person-centered service plan, including potential qualified providers, coordinating with the individual’s care coordinator or community mental health program when applicable; and

(d) Monitors the delivery of authorized services.

(28) "Service Need" means the amount, scope, and duration of personal care and supportive services that are medically necessary and appropriate for an individual as determined through a personal care services’ needs-based assessment and documented with specificity in the individual’s person-centered service plan.

(29) "Service Period" means two consecutive work weeks for a total of 14 days.

(30) "Skills, Knowledge, and Ability to Adequately or Safely Perform the Required Work" means a personal care attendant or direct support worker possesses and demonstrates the physical, mental, organizational, and emotional skills or abilities necessary to perform services which safely and adequately meet the service needs of individuals.

(31) “Termination” means a sanction prohibiting a provider’s participation in the Authority’s programs by cancelling the Authority-assigned billing number and agreement for a personal care attendant or Agency with Choice. No payments, Title XIX, or state funds will be made for services provided on and after the date of termination. An Agency with Choice may also have their license denied, suspended, or revoked as outlined in OAR 309-045-0320.

(32) "Unwelcome Nuisance to the Workplace" includes, but is not limited to, unwelcome guests or pets invited by a personal care attendant or a direct support worker into an individual’s home, unwelcome behaviors, or unwelcome items resulting in the individual’s dissatisfaction or a personal care attendant’s or a direct support worker's inattention to the individual's required service needs.

History

Statutory/Other Authority: ORS 413.042, ORS 414.065 & Oregon Laws 2024, Ch. 37
Statutes/Other Implemented: ORS 414.065, 430.731 & Oregon Laws 2024, Ch. 37
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 39-2022, adopt filed 03/24/2022, effective 03/24/2022

Or. Admin. R. 410-172-0780 Temporary rule language in effect until 02/15/2027. State Plan Personal Care Services and Limitations

(1) The State Plan Personal Care (SPPC) program provides essential personal care services that enable an individual to move into or remain in their own home, family home, another private residence or temporary living arrangement.

(a) Personal care services available through the SPPC program are provided directly to an individual who is determined to be eligible in accordance with OAR 410-172-0790.

(b) Personal care services are not intended to provide respite and they are not intended to substitute for the individual’s natural or other support systems that are available to them. Personal care services must be medically necessary and appropriate and must not be provided for the purpose of benefiting an individual’s family members or the individual’s household.

(2) Eligible individuals who are authorized by the Authority to receive personal care services may be approved to receive up to 270 hours of personal care services in a twelve-month period, unless an exception request is approved by the Authority.

(a) The actual number of hours of personal care services that an individual is authorized to receive are identified in the individual’s person-centered service plan (PCSP). An individual’s PCSP is developed as outlined in OAR 410-172-0790. The twelve-month period (PCS plan year) begins on the date the individual is determined eligible for the SPPC program unless otherwise modified through an exception request by the Authority.

(b) When an individual’s personal care service needs are assessed as exceeding the annual maximum of 270 hours in a PCSP year, an individual or their authorized representative, has the right to request an exception. Exception requests must be submitted in writing on behalf of the individual by the service coordinator and must identify all of the following:

(A) The exceptional personal care needs the individual is experiencing;

(B) The tasks that require hands-on assistance or direct supervision and cueing every time they occur; and

(c) The Authority has up to 45 days upon receipt of an exception request to determine whether an individual’s assessed personal care needs warrant exceeding the 270-hour per PCS plan year limitation and issue written notice to the individual;

(d) The individual id provided a written notice of action or service authorization within 10 days after the Authority’s decision.

(3) Personal care services include:

(a) Activities of Daily Living (ADLs):

(A) Eating includes assisting the individual in feeding or fluid intake by any means from a receptacle into the body. Includes monitoring to prevent choking or aspiration;

(B) Bathing includes assisting the individual with cleansing the body, washing hair, shaving, nail care, and using assistive devices when necessary to get in and out of the bathtub or shower;

(C) Dressing includes assisting the individual with putting on, fastening, and taking off all items of clothing, braces, and artificial limbs, including obtaining and replacing items from their storage area in the immediate environment;

(D) Toileting includes assisting the individual in getting to and from, on and off the toilet, commode or bedpan for elimination of feces and urine. This includes cleansing after elimination and adjusting clothing as necessary;

(E) Maintaining Continence includes assisting the individual with external cleansing of Foley catheter, emptying catheter drainage bag, maintenance bowel care, changing and replacing incontinence products, including colostomy or ileostomy bags; and

(F) Transferring includes assisting the individual with transfers between positions, ambulation (walking) and repositioning by any means including use of an assistive device and includes turning or adjusting padding for physical comfort or pressure relief and encouraging or assisting with range of motion exercises.

(b) Instrumental Activities of Daily Living (IADLs) includes:

(A) Personal Hygiene includes performing or assisting the individual with activities required to keep one’s desired appearance including secure or fasten clothing, comb/brush hair, nail care, foot care, skin care, and mouth care and oral hygiene;

(B) Light Housework includes performing or assisting the individual with housekeeping tasks necessary to maintain the individual in a healthy and safe living environment;

(C) Laundry includes performing or assisting the individual with laundering or cleaning of clothing, bedding and other linens;

(D) Meal preparation includes performing or assisting the individual with healthy meal planning and preparation, ensuring special diets are followed;

(E) Shopping includes performing or assisting the individual in planning for and purchasing of essential items including clothing, groceries, prescribed medication, hygiene products and basic household necessities;

(F) Using the Telephone or other Electronic Communication Devices include performing or assisting the individual in arranging necessary appointments and making desired phone calls using a telephone, smart phone, tablet or other similar electronic device for communication purposes;

(G) Medication assistance includes helping individuals with oral medications prescribed for the individual by a licensed medical professional, which are ordinarily self-administered described below:

(i) Administering medication;

(ii) Supervision or cueing to ensure the individual is taking medication as prescribed;

(iii) Documenting and monitoring any notable side effects;

(iv) Refilling prescriptions; and

(v) Assisting with use, maintenance, and cleaning of in-home medical equipment authorized by a licensed medical professional, monitoring the individual’s condition, ordering and maintaining necessary supplies. Use, maintenance and cleaning of in-home medical equipment must be performed by PCA in compliance with manufacturers guidelines or the PCA must have received prior training and education from an RN, when applicable, in how to correctly perform these tasks. Providing assistance with insulin injections and other similar medical tasks requires prior training and education from an RN, which is a delegated nursing task.

(H) Money Management includes performing or assisting the individual with budgeting, making payments for monthly expenses and use of personal funds for desired items and activities; and

(I) Transportation includes assisting the individual, due to a functional limitation, in getting to and from medically appropriate and necessary appointments and community activities, consistent with the individual’s authorized PCSP and personal care needs, and does not duplicate services otherwise available through non-Medicaid transportation benefits. Transportation benefits may include:

(i) Scheduling non-emergent medical transportation (NEMT) for their OHP-covered medical service appointments;

(ii) Scheduling non-medical rides through public transportation or other modes of transportation;

(iii) Accompanying the individual to and from appointments or community activities;

(iv) Transporting the individual in the PCA’s or DSW’s personal vehicle in accordance with section (4) below of this rule.

(4) PCAs and DSWs may use their personal vehicles to transport individuals as outlined in this section.

(a) Both PCAs and DSWs must:

(A) Prior to transporting the individual, submit proof of current vehicle registration and insurance for the personal vehicle used to transport the individual and a current valid driver’s license to:

(i) The individual's service coordinator for PCAs; or

(ii) Agency with Choice (AWC) for DSWs; and

(B) Claim mileage and request reimbursement only when the transportation provided is authorized in the individual’s current PCSP.

(i) PCAs must submit their claims for mileage reimbursement to the Authority, which will be paid at the rate identified in the current collective bargaining agreement.

(ii) DSWs must submit their claims for reimbursement to the AWC that employs them.

(b) Mileage may be reimbursed by the Authority for OHP covered medical appointments when:

(A) One or more providers have documented in the individual's medical record that the individual will need non-emergency medical transportation for future, specific dates of service using the PCA’s or DSW’s vehicle;

(B) The need for non-emergency medical transportation is included in the individual's PCSP or made a part of the PCSP after receipt of the documentation provided under (A) but before the specified date(s) of services; and

(C) As determined by OHA in its reasonable discretion after a review of all the circumstances, including whether the denial by NEMT was reasonable.

(c) PCAs will be paid for travel time between individual’s homes or initial service-related sites (e.g., pharmacy, grocery store) occurring on the same day. Travel time will be calculated based on the most direct route possible. PCAs using public transportation, the posted time between stops will be used to calculate and validate travel time. Travel time will be paid at base pay for Providers as defined in Appendix A of the collective bargaining agreement. Travel time pay is not subject to Oregon Home Care Commission (OHCC) certification pay differentials. This subsection (c) does not apply to DSWs.

(5) Personal Care Services include other services as follows:

(a) Delegated nursing includes nursing tasks that are delegated by a Registered Nurse currently licensed and in good standing with the Oregon Board of Nursing, to a licensed provider or other non-licensed persons in accordance with OAR chapter 851, division 47. Skilled services delegated by a Registered Nurse (RN) under Oregon’s Nurse Practice Act may be considered personal care services when the RN provides appropriate training and delegation of the listed nursing tasks in accordance with the Oregon Nurse Practice Act; and

(b) Personal care services may be required when an individual has the physical capability to perform ADL or IADL tasks but due to mental health conditions the individual does not know how or when to carry out those tasks. In such situations, personal assistance may include cueing along with supervision to ensure the individual performs the task safely. An individual may also have co-occurring physical disabilities that contribute to the need for assistance.

(6) Services that are not outlined in sections (3) through (5) above are not eligible for payment. The Authority will not pay a PCA or an AWC when the PCA or the DSW provides any of the following excluded services:

(a) Shopping for entertainment purposes or non-essential items;

(b) Social companionship;

(d) Care, grooming, or feeding of pets or other animals except those incidental to other authorized ADL or IADL tasks; or

(e) Yard work, gardening or home repair.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0790 Temporary rule language in effect until 02/15/2027. Eligibility for State Plan Personal Care Program Services

(1) In order to be authorized by the Authority to receive State Plan Personal Care (SPCC) services, individuals must:

(a) Apply for the SPPC program as outlined in OAR 410-172-0796;

(b) Meet the initial eligibility criteria identified in section (2) of this rule;

(c) Meet with the Authority’s designated IQA or the IQA’s Service Coordinator to administer a needs-based assessment outlined in OAR 410-172-0830;

(d) Be able to demonstrate as determined through the needs-based assessment, the skills necessary to:

(A) Have the knowledge, skills and capacity necessary for meeting the obligations of an employer of a personal care attendant (PCA) as outlined in OAR 410-172-0800; or

(B) Having the knowledge, skills and capacity necessary for meeting the obligations of a co-employer of a direct support worker (DSW) as outlined in OAR 410-172-0845.

(e) Participate in the development of a Person-Centered Service Plan led by the Authority’s designated IQA or the IQA’s Service Coordinator; and

(f) Provide, when available and as reasonably requested by the Authority, the necessary information and documentation to assist the IQA in assessing the functional needs, including medical records and other provider documentation.

(2) An individual of any age is eligible for personal care services through the SPPC program if they meet all of the other criteria as follows:

(a) Be enrolled in a Medicaid OHP Plus benefit package;

(b) Not be in foster care;

(A) The presence of mental health symptoms or a mental health condition; and

(B) A medically necessary need for assistance with at least one ADL or IADL due to a functional limitation that, without assistance, would adversely affect the individual’s health, safety or welfare, as determined through the Authority’s needs based-assessment.

(3) Subject to the individual meeting the criteria of sections (1) and (2) of this rule, the Authority will prior authorize the individual’s person-centered service plan (PCSP) before they can participate in the SPPC program.

(4) An individual is not eligible to receive personal care services through the SPPC program and will not participate in a needs-based assessment if:

(a) The individual is receiving personal care services from a licensed 24-hour residential services program that includes but is not limited to a foster home, residential treatment home, or residential treatment facility;

(b) The individual is in jail, prison, or other detention facility; hospital, sub-acute care facility; nursing facility; Institution for Mental Disease (IMD); Intermediate Care Facility for Individuals with Intellectual or Developmental Disabilities (ICF/IDD); or other medical institution;

(c) The individual’s assessed service needs are being met under other Medicaid-funded home and community-based service options of the individual’s choosing;

(d) The individual's assessed service needs are met through the individual's natural support system as defined in these rules; or

(e) The individual meets any criteria under excluded services and limitations as described in OAR 410-120-1200.

(5) SPPC services are not intended to replace routine care commonly needed by an infant or child that is typically provided by the infant’s or child’s parent.

(6) SPPC services must not be used to:

(a) Replace or duplicate services available from other non-Medicaid governmental programs; or

(b) Duplicate other Medicaid services.

(7) The Authority may withdraw an individual’s eligibility determination or service authorization, or both, for SPPC services as outlined below in this rule:

(a) An individual’s eligibility determination or service authorization may be withdrawn by the Authority if an individual fails to:

(A) Employ a qualified provider either as a PCA as described in OAR chapter 418 division 020 or signs an agreement with the Agency with Choice to initiate services as described in OAR chapter 309 division 045 within 45 days of service authorization; or

(B) Receive personal care from a qualified provider paid by the Authority at any time for a period of 30 continuous calendar days or longer.

(b) If an individual’s eligibility determination or service authorization is withdrawn by the Authority, the Authority will provide the individual and as applicable, the individual’s Authorized Representative, a notice of action that complies with OAR 410-120-1865; or

(c) If an individual’s eligibility determination or service authorization is withdrawn by the Authority, the individual has the right to be reauthorized for SPPC services, or reapply to the SPPC program, as set out in OARs 410-172-0774 through 410-172-0840.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0796 Temporary rule language in effect until 02/15/2027. Applying for State Plan Personal Care Program Services

(1) Individuals of any age may apply for the SPPC program services through the Authority. Eligibility is determined based on the criteria described in OAR 410-172-0790(1).

(a) If the Authority determines an individual is eligible for the SPPC program as described in 410-172-0790(1), the individual must:

(A) Participate in a needs-based assessment performed by the Authority’s IQA as outlined in 410-172-0830; and

(B) Be approved to receive SPCC services based on the needs-based assessment.

(b) Individuals applying for SPPC services who are not eligible for SPPC through the Authority but meet or may meet one or more of the eligibility requirements in section (2) or (3) below of this rule, may be referred to the Department's Office of Developmental Disabilities Services (ODDS) or Department's Office of Aging and People with Disabilities (APD).

(2) An individual with an intellectual or developmental disability eligible for or receiving services through ODDS, a Community Developmental Disability Program (CDDP), or Support Services Brokerage as described in OAR 411-034-0035 may apply for SPCC services through the local CDDP or the local support services brokerage.

(3) An older adult or an adult with a disability eligible for or receiving case management services from APD or Area Agency on Aging (AAA) as described in OAR 411-034-0035 may apply for SPPC services through the local APD or AAA office.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 39-2022, adopt filed 03/24/2022, effective 03/24/2022

Or. Admin. R. 410-172-0800 Temporary rule language in effect until 02/15/2027. Employer and Co-Employer Responsibilities

(1) The individual or the individual’s authorized representative retains employer responsibilities for workers providing personal care services, including personal care attendants (PCA) and direct support workers (DSW). For purposes of OARs 410-172-0774 through 410-172-0845, an authorized representative who fulfills consumer-employer responsibilities described in this rule on behalf of the individual is sometimes referred to as a “Consumer Employer Representative (CER).”

(2) If an individual is authorized to receive personal care services and elects to employ a PCA or co-employ a DSW, the individual or the individual’s authorized representative will be required to perform the following:

(a) Identify, screen, and hire a PCA or identify, screen and choose a DSW employed by the Agency with Choice (AWC);

(b) Supervise and train a PCA or DSW;

(d) Direct the PCA or DSW in the provision of personal care services;

(e) Verify the authorized hours completed by a PCA or DSW through an Authority approved electronic visit verification (EVV) method when required by state or federal law;

(f) Recognize PCA or DSW performance deficiencies. Upon recognition of performance deficiencies, the individual or the authorized representative must be able to:

(A) Discuss the performance deficiencies with the PCA or DSW;

(B) Work with the PCA or DSW to correct the performance deficiencies; and

(g) Discharge a PCA or DSW who does not perform tasks in accordance with these rules or to the reasonable satisfaction of the individual; and

(h) Comply with all federal and state laws related to employer responsibilities, including ensuring a safe work environment.

(3) An individual or their authorized representative and the PCA or DSW may, at their election, enter into a written agreement that describes their respective responsibilities and obligations as outlined in section (1) above of this rule, and other terms and conditions so long as those terms and conditions of the working relationship, does not conflict with or violate state and federal laws, the administrative rules governing the State Plan Personal Care (SPPC) program, and any applicable collective bargaining agreement or, in the case of a DSW, any policies or procedures required by the AWC.

(a) A written agreement is optional and does not limit the individual’s authority to discharge a PCA or DSW in accordance with section (4) of this rule.

(b) Other terms and conditions that may be incorporated in the individual agreement include but are not limited to:

(A) Requiring a notice of resignation to be submitted by the PCA or DSW;

(B) Identifying general expectations regarding performance; and

(C) Providing procedures on how to inform the individual of the need to stay home due to illness or otherwise miss a scheduled workday.

(4) The individual or the individual’s authorized representative retains the right to select, supervise, and discharge a PCA or DSW, consistent with applicable law The grounds for discharging a PCA or DSW are determined by the individual or the individual’s authorized representative but may include without limitation:

(a) Circumstances identified in an individual written agreement that was signed by the PCA or as applicable, the DSW, and the individual or their authorized representative; or

(b) Other reasons identified by the individual or authorized representative, provided such discharge does not violate applicable laws and any applicable collective bargaining agreement.

(5) When an individual elects to receive services through an AWC:

(a) The individual retains the employer responsibilities described in this rule, consistent with the co-employer role defined in applicable AWC rules as described in chapter 309 division 045; and

(b) The AWC provider carries out agency and employer-of-record responsibilities in accordance with applicable rules and contracts.

(6) An individual may designate an authorized representative to act on their behalf to meet the co-employer responsibilities described in this rule:

(a) If an individual has a legal representative, the legal representative may designate themselves or another individual as the individual’s authorized representative; and

(b) The Authority has the right to deny the designation of an authorized representative as outlined in OAR 410-172-0805.

(7) An individual who is unable to meet the employer or co-employer responsibilities in this rule may be determined ineligible for personal care services.

History

Statutory/Other Authority: ORS 413.042, ORS 414.065 & Oregon Laws 2024, Ch. 37
Statutes/Other Implemented: ORS 414.065, 430.731 & Oregon Laws 2024, Ch. 37
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0805 Temporary rule language in effect until 02/15/2027. Authorized Representative Disqualification

(1) The Authority has the right to deny the designation of an authorized representative if the authorized representative has:

(a) A history of a substantiated abuse of an adult as described in OAR chapter 411, division 20, OAR chapter 419 division 110 or OAR chapter 943 division 45;

(b) A history of founded abuse of a child as described in ORS 419B.005;

(c) Participated in excessive billing, outside of services approved in the individual’s service plan, or fraudulent charges; or

(d) Has failed to meet, or has, in the past, had their authorized representative designation terminated for failing to meet the employer responsibilities described in section (1) of this rule.

(2) An individual may select another authorized representative if the Authority suspends, terminates or denies an individual’s designation of authorized representative.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 36-2026, temporary adopt filed 08/20/2026, effective 08/20/2026 through 02/15/2027

Or. Admin. R. 410-172-0820 Temporary rule language in effect until 02/15/2027. Personal Care Attendant Eligibility, Sanctions and Termination

(1) A personal care attendant (PCA) must meet qualifications in OAR Chapter 418, Division 020, including being at least 18 years of age, and must not be:

(a) The individual’s spouse;

(b) The parent or legal representative of a minor individual; or

(2) A person can submit an application to become a PCA to the Authority’s IQA and complete required training as described in OAR chapter 418, division 020.

(3) The Authority may deny, suspend, or terminate a PCA’s s provider enrollment or re-enrollment and their assigned provider number or impose another sanction on the PCA, as described in OAR chapter 410 division 120.

(4) In addition to the Authority’s rights under section (5) below of this rule and OAR chapter 410, division 120, the Authority has the right to immediately suspend a PCA’s provider enrollment and assigned billing number when the Authority has reasonable cause to believe there is an imminent danger or risk of imminent danger to an individual’s life, physical, emotional, or financial well-being.

(5) If the Authority determines if it’s necessary to immediately suspend a PCA’s provider enrollment and assigned billing number:

(a) The Authority will issue to the PCA a notice that the PCA’s provider enrollment is immediately suspended in accordance with 410-120-1460(5); and

(b) The PCA may appeal the immediate suspension as outlined in OAR 410-120-1460(7) and 410-120-1560 through 410-120-1600; and

(6) In addition to exercising its right to immediately suspend a PCA’s provider enrollment and assigned provider number as outlined in section (2) this rule, the Authority may also deny, suspend, or terminate a PCA’s provider enrollment and assigned provider number or impose another sanction when the PCA:

(a) Has been appointed the authorized representative or legal representative of an individual, is the individual’s spouse, or is the parent or legal representative of a minor individual;

(b) Fails to obtain a background check in accordance with OAR chapter 943, division 007, as required in writing by the Authority or has a background check that results in an adverse fitness determination;

(c) Lacks the skills, knowledge, or ability to perform the required work as described in these rules and OAR chapter 418, division 020;

(d) Forged or otherwise falsified one or more credentials, education or training documentation, or other records submitted to the Authority to obtain approval as a PCA ;

(e) Violates the protective service and abuse rules described in OAR Chapter 413, division 15, OAR chapter 411, division 20, or OAR chapter 419, division 110;

(f) Commits one or more Fiscal Improprieties as defined in OAR 410-172-0776;

(g) Fails to provide the authorized personal care services;

(h) Coerces or colludes with the individual to sign or approve false, blank or inaccurate time entries or documents false or inaccurate information in the EVV system;

(i) Fails to arrive and depart work at a date and time documented in the work schedule authorized by the individual;

(j) Fails to maintain a drug-free workplace which requires:

(A) Refraining from manufacturing, possessing, selling, offering to sell, trading, or using illegal drugs while providing personal care services to an individual; and

(B) Not being under the influence of substances that inhibit a PCA’s ability to provide personal care services when responsible for the care of an individual. Substances that inhibit a PCA’s ability to perform personal care services include without limitation, any one or more of the following:

(i) Alcohol, inhalants, marijuana, marijuana edibles, marijuana tinctures; and

(ii) Illicit drugs, legal drugs, and other drugs including prescription drugs, over-the-counter medications, or other similar substances that may inhibit a PCA’s ability to provide personal care services, while responsible for the care of an individual.

(k) Has been or is currently excluded as a provider by the U.S. Department of Health and Human Services, Office of Inspector General from participation in Medicaid, Medicare, or any other state or federal health care programs;

(l) Has been sanctioned or convicted of a felony or misdemeanor related to a crime, or violation of Title XVIII, XIX, or XX of the Social Security Act, or related state laws;

(m) Fails to maintain confidentiality, security and privacy of protected health information, as required by HIPAA and State privacy laws;

(n) Exerts undue influence, including coercion, over an individual or their authorized representative;

(o) Introduces or creates an unwelcome nuisance to the workplace as determined by the individual;

(p) Fails to perform the duties of a mandatory reporter defined in ORS 419B.010 and ORS 430.765;

(q) Fails to inform the Authority and their consumer-employer within 14 days of being arrested, cited for, or convicted of any potentially disqualifying crime listed in OAR 125-007-0270;

(r) Fails to meet one or more of the mandatory training and competency evaluation requirements described in OAR 418-020-0035;

(s) Is an employee of the Oregon Health Authority’s Medicaid or Behavioral Health Divisions, OHA’s Independent and Qualified Agent, the Oregon Department of Human Services (ODHS), the Oregon Home Care Commission (OHCC), or any other entity with the ability to assess for or authorize personal care services for the State Plan Personal Care (SPPC) program;

(t) Fails to adhere to the hourly cap described in the CBA or to the service limitations in the service authorization or service plan;

(u) Knowingly engages in activities that may pose risks to the health and safety of an eligible individual, or others in the community, including exposure to an infectious disease;

(v) Engages in discrimination of others based on race, national origin, color, sex, gender identity, sexual orientation, age, religion, physical, intellectual, developmental, or mental disability, military status, or marital or family status and as described in OAR 410-120-1380(1)(c)(A);

(w) Offers or provides services that are not authorized, including using authorized service time for non-covered services, or charging an individual for services outside the service plan; or

(x) Knowingly submits or causes to be submitted information or documents that contain inaccurate, misleading, or omitted information and such inaccurate, misleading, or omitted information would result, or has resulted, in an overpayment.

(7) The Authority may suspend a PCA and PCA payments in the event it has determined there is suspected fraud or abuse or a credible allegation of fraud as described in OAR 410-120-1510.

(8) If the Authority intends to suspend or terminate a PCA’s provider enrollment and assigned provider number or impose one or more other sanctions under sections (4) or (5) of this rule and that misconduct does not pose an imminent risk to the individual:

(a) The Authority will notify the PCA via certified mail, personal delivery, or other traceable delivery services, such as email, as outlined in OAR 410-120-1460(5)-(6); and

(b) The PCA may appeal the suspension, termination, or sanction as outlined in OAR 410-120-1460 (7) and 410-120-1560 through 410-120-1600 so long as the appeal is not prohibited under section (6) of this rule.

(9) The Authority also has the right to take other actions as set forth in OAR 410-120-1460(8).

(10) The following situations are excluded from the provider appeal process described in this rule:

(a) Terminations or renewal denials based on a background check required prior to enrollment and every two years while enrolled. A PCA who receives a denial notice from the background check unit has the right to a hearing in accordance with OAR 407-007-0200 to 407-007-0370. PCAs will not receive a separate notice from the Authority when terminations or denials are issued as a result of a background check;

(b) Termination due to inactivity or no proof of participation for a period of 18 months or more;

(c) Denial of provider enrollment or reenrollment based on an applicant’s or a PCA’s failure to provide required and accurate information or information requested by the Authority for a provider enrollment number within the time limits identified in Authority’s letter with initial application or revalidation of the provider enrollment.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065, 430.735 & 410.600
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 4-2023, amend filed 02/16/2023, effective 02/17/2023
DMAP 70-2022, temporary amend filed 08/16/2022, effective 08/31/2022 through 02/26/2023
DMAP 46-2022, minor correction filed 04/15/2022, effective 04/15/2022
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0830 Temporary rule language in effect until 02/15/2027. Service Assessment, Authorization and Reassessment

(1) The Authority is responsible for administering the State Plan Personal Care (SPPC) program and may contract with a designee, known as the Independent and Qualified Agent (IQA) and other qualified contracted parties, to fulfill some of the Authority’s administrative obligations with respect to assessment, authorization, and monitoring of SPPC services provided to individuals.

(2) After an individual is referred and applies for SPPC services, the Authority is responsible for the following:

(a) Receiving and processing requests for personal care services from any source; and

(b) Designating a service coordinator who is a qualified mental health professional to conduct needs-based assessments of individuals using Authority approved tools to determine an eligible individual’s level of need for personal care services.

(3) The tools used to perform needs-based assessments enable the service coordinator to:

(a) Determine the ability of individuals to perform the ADL, IADL, and other personal care activities and tasks; and

(b) Assess an individual’s service needs, identify the resources required to meet the individual’s needs and determine if the individual is eligible for other approved programs or other services.

(4) Needs-based assessments are required to be performed when:

(a) The initial request for personal care services is received;

(b) At least every 12 months after the individual’s first needs-based assessment was performed if that first assessment resulted in an authorization of personal care services;

(c) When requested by the individual or their authorized representative after they have been authorized and started receiving personal care services even if there has been less than 12 months since the last needs-based assessment was performed; and

(d) When the individual’s circumstances or needs change.

(5) When an individual is reassessed for service need (needs-based reassessment) as required under section (2) above of this rule, the Authority will designate a service coordinator to perform the reassessment.

(a) The service coordinator must determine whether:

(A) Individual meets all service eligibility criteria;

(B) Individual’s person-centered service plan (PCSP), as described in OAR 410-172-0776, is cost effective;

(D) Personal care services provided meet the individual’s identified service needs.

(b) If the individual remains eligible for the SPPC program the service coordinator must:

(A) If needed, revise the PCSP as outlined in OAR 410-172-0776;

(B) If needed, adjust the number of hours authorized, the types of personal care services included in the individual’s service plan, or both;

(D) Provide the individual’s approved tasks and hours to the designated OHA staff member to process for submission to the applicable EVV system.

(6) Each individual who participates in a SPPC needs-based assessment and reassessment will be provided with a notice of action advising whether they have been approved for or denied SPPC services.

(a) If the SPPC services are approved in full or in part, the notice will identify the scope, amount, and duration of the services approved.

(b) If the SPPC services are denied in full or are approved but in an amount, scope, and duration that is less than requested, the individual’s notice, called a notice of adverse benefit determination (NOABD), will provide the individual with information regarding their right to a contested case hearing as outlined in OARs 410-120-1855, 410-120-1860, and 410-120-1865.

(d) Providers requesting the SPPC services on behalf of an individual will receive the same notice the individual receives as outlined in OARs 410-120-1860 and 410-120-1865.

(7) The service coordinator shall meet with the individual when performing the needs-based assessment. The individual and the service coordinator may meet in person or using, telehealth technology. The individual has the right to choose whether to meet with the service coordinator in person or via telehealth.

(a) An individual’s natural supports may attend, and if needed participate in, the needs-based assessment if requested by the individual or their authorized representative, if applicable;

(b) An individual’s authorized representative may also attend, and if needed participate in, the needs-based assessment.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0835 Temporary rule language in effect until 02/15/2027. Person-centered Service Planning, Coordinating and Monitoring

(1) When the needs-based assessment demonstrates that personal care services are medically necessary and appropriate, the service coordinator will develop a person-centered service plan (PCSP). The individual has the right, but is not required to, participate in the development of the PCSP.

(2) A completed PCSP must identify the tasks for which an individual requires assistance and the number of authorized service hours, and individual’s natural supports who currently meet some or all the individual’s service needs.

(a) The PCSP must describe:

(A) The tasks the personal care attendant (PCA) or the Agency with Choice (AWC), including the direct support worker (DSW), will perform;

(B) The maximum authorized hours that the individual may receive personal care services during each 14-day pay period; and

(b) The service coordinator must consider the cost effectiveness of medically necessary and appropriate services when developing the individual’s PCSP.

(3) The service coordinator will provide ongoing coordination of services, including:

(a) Authorizing changes in PCAs, DSWs, and other providers and service hours;

(b) Addressing risks;

(d) Providing information to the individual; and

(e) Making referrals to other providers for the individual when indicated.

(4) The service coordinator will monitor the personal care services provided to the individual to ensure the PCSP is effectively implemented and continues to meet the needs of the individual. Monitoring will occur at least every quarter of the service plan year and more frequently if requested by the individual, the individual’s authorized representative or legal representative (or both if different), or if determined necessary by the service coordinator.

(a) Monitoring requires:

(A) The individual and the service coordinator to meet in-person, face-to-face using telehealth, or telephone interviews. The meeting may include the individual’s authorized representative or legal representative (of both if different);

(B) Monitoring preferences shall be determined by the individual or their authorized representative; and

(C) The service coordinator must meet with the individual for in-person or face-to-face telehealth monitoring at least once annually, or more often, as determined by the individual or their authorized representative or legal representative (or both if different), or the service coordinator.

(b) The service coordinator must document all monitoring activities in the individual’s record, which must identify, at minimum, the following:

(A) Identification of the personal care services delivered in accordance with the individual’s PCSP and applicable Oregon Administrative Rules;

(B) Whether and how the PCSP adequately meets the individual’s assessed needs and goals;

(D) Any follow-up actions needed to be performed and by whom to ensure the PCSP is adjusted to meet the individual’s needs.

(5) The Authority may not authorize the delivery of personal care services in an individual’s home or family home when:

(a) The individual’s home or family home presents conditions that jeopardize the health or safety of the individual, their PCA, or their DSW and cannot be mitigated through reasonable safeguards;

(b) The services cannot be provided safely by the PCA or DSW in the individual’s home or family home;

(c) The individual is unable to make informed decisions, and, as applicable, does not have an authorized representative to make decisions on their behalf, and necessary safeguards cannot be implemented to protect the individual’s safety, health, and welfare; or

(d) The individual is unable to fulfill employer or co-employer responsibilities, as applicable, and does not have an authorized representative to perform those responsibilities.

(6) The service coordinator shall provide the individual or the individual’s representative with information on service alternatives and assist with exploring other options when a PCA or a DSW employed by an AWC is not authorized. Eligible individuals have free choice of qualified providers of in-home care services.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 413.042 & 414.065
DMAP 36-2026, temporary adopt filed 08/20/2026, effective 08/20/2026 through 02/15/2027

Or. Admin. R. 410-172-0840 Temporary rule language in effect until 02/15/2027. State Plan Personal Care Payment Limitations

(1) The number of personal care service hours authorized through the State Plan Personal Care (SPPC) program for an individual per 14-day service period is based on projected time needed to perform specific personal care services and is subject to the following:

(a) Authorization of hours does not guarantee the personal care attendant (PCA) or the direct support worker (DSW) will work all authorized hours;

(b) The total of these hours is limited to 270 hours per individual per service plan year unless an exception has been granted in writing by the Authority; and

(2) The Authority will pay for medically necessary and appropriate SPPC services only when provider enrollment standards in OAR 410-120-1260, OAR chapter 418 division 020, and this rule are met, and both the individual and provider have been notified in writing that payment by the Authority is authorized.

(3) The Authority shall make payment for personal care services through the approved program to the provider on an eligible individual’s behalf. Payment for services is not guaranteed.

(a) To receive payment the provider must be an enrolled Provider as required by OAR 410-120-1260, meet all requirements of this rule and the Authority must verify that an individual’s provider meets the qualifications set forth in OAR chapter 418, division 020.

(b) The Authority will only make payment to a provider for personal care services when those personal care services are fully documented as required by OAR 410-120-1360 and 410-172-0620, comply with all State and Federal EVV requirements, and Authority rules for Medicaid payment and recordkeeping OAR 410-120-1280, OAR 410-120-1340, and OAR 410-120-1360.

(c) Only valid, complete and error-free claims are paid to providers. The PCA or DSW must use an Authority-approved EVV method to verify all personal care services.

(d) The EVV and all personal care services records are subject to Authority pre-payment and post-payment review. The Authority will review billings, EVV, provider documentation, and other medical information for accuracy, medical appropriateness, level of service, correct coding, or for other reasons subsequent to payment of the claim.

(e) Payment may be denied, adjusted, or recovered if errors or improper payment are identified by a pre-payment or post-payment review, consistent with OAR 410-120-1396 and OAR 410-120-1397.

(4) Provider claims for payment must meet the following requirements:

(a) In accordance with OAR 410-120-1300, all provider claims for payment must be submitted within 12 months of the date of service;

(b) For SPPC delivered by a PCA the Authority will pay the standardized rate as described in the CBA in effect on the date of service; and

(c) Providers must submit accurate and complete claims and adequately document services via a Authority approved EVV method and as required by OAR 410-120-1260 to receive payment from the Authority.

(5) Payment may not be claimed until the hours authorized for the payment period have been completed.

(6) Payments made to a provider are calculated to a single attendant and a single eligible individual as follows:

(a) A PCA shall not bill or receive payment for two or more individuals at the same time on the same day of service; and

(b) An Agency with Choice provider may not bill for overlapping services delivered by its DSWs.

(7) Payments will not be made for personal care services during time periods when the individual is admitted to a hospital or facility.

(8) Provider billing for personal care services must comply with Authority rules for Medicaid payment. Providers and the IQA must meet the following requirements to be considered valid:

(a) The individual was eligible to receive Medicaid personal care services on the date of service;

(b) The service billed was included in the individual’s approved service plan;

(d) The services were provided in a community setting and location approved in the individual’s service plan; and

(e) The provider met all applicable enrollment, documentation and record-retention requirements, and program integrity obligations, such as disclosing and returning identified overpayments.

(9) All payments to providers are subject to pre-payment and post-payment review as follows:

(a) The Authority will review billings, EVV, work schedule records or other medical or financial information for accuracy, medical appropriateness, level of service, or for other reasons subsequent to payment of the claim;

(b) Payment by the Authority does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit claims before or after the payment;

(c) Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the service was not provided in accordance with applicable rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment; and

(d) The Authority will conduct post-payment reviews as described in OAR 410-120-1396.

(10) Providers and any entity billing the Authority on behalf of the provider, must submit true, accurate, and complete claims and encounters to the Authority. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certification of truth, accuracy and completeness. Providers that falsify or conceal a material fact in the submission of claims and encounters may be prosecuted under federal and state laws.

(11) Providers must comply with OAR 410-120-1510, OAR 461-195-0601 and the requirements therein for prompt reporting of fraud, waste and abuse in the Medicaid program. Information on how to report may be found online at all times: https://www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx

(12) A person debarred, excluded, suspended, or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license or certification to practice is suspended or revoked by a state licensing board shall not submit claims for payment in compliance with OAR 410-120-1380.

(13) The Authority may suspend a SPPC provider and provider payments in the event it has determined there is suspected fraud or abuse as described in OAR 410-120-1500. Authority will suspend provider enrollment and any payments, in whole or in part, when a credible allegation of fraud exists pursuant to federal law under 42 CFR 455.23, whether presented to the Authority, Oregon Department of Human Services (ODHS), Department of Justice (DOJ), Medicaid Fraud Control Units (MFCU), or law enforcement entity; unless there is a pending investigation and good cause exists to continue payment.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022
DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0845 Temporary rule language in effect until 02/15/2027. Agency with Choice Provider Requirements

(1) An Agency with Choice (AWC) is a qualified provider under this rule so long as it meets all applicable standards in OAR chapter 309, division 045 including provider enrollment, service delivery, background checks, critical incident reporting, and co-employer responsibilities.

(2) An AWC must enroll with the Authority as a Medicaid provider in accordance with OAR 410-120-1260.

(3) To remain a qualified provider of SPPC program services, an AWC must maintain a valid license issued under OAR chapter 309, division 045 and comply with all applicable provider and program integrity requirements in OAR 943-120-0300 through 943-120-0350.

(4) An AWC and its direct support workers (DSW) must provide all SPPC program services in accordance with this rule, OARs 410-172-0774 through 410-172-0840, OAR chapter 309, division 045, and all other applicable state and federal laws.

(5) AWC services provided under this rule, inclusive of assistance with ADLs and IADLs provided by DSWs, must be authorized within the individual’s person-centered service plan (PCSP) developed by the IQA.

(6) In accordance with ORS 443.360, an AWC serves as the employer of record for DSW. The AWC is responsible for paying the DSWs employed by the AwC, complying with all applicable wage and hour laws, paying all payroll and other applicable taxes, and complying with Electronic Visit Verification (EVV) requirements. In addition, an AWC:

(a) Serves as employer of record for all DSWs providing services under this rule;

(b) Ensures all employees and contractors, including DSWs, meet background check and training requirements prior to service delivery;

(c) Provides or ensures and documents completion of Authority-approved orientation and training for all DSWs prior to the delivery of services;

(d) Implements and maintains an Authority-approved EVV system to record service delivery consistent with OAR 410-120-1360 and 42 U.S.C. 1396b(l); and.

(e) Maintains documentation of all services provided, including EVV records, PCSP authorizations, and payroll records.

(7) An AWC must, in accordance with OAR chapter 309, division 045, use Medicaid payments only for authorized service delivery, wages, benefits, and administrative costs directly related to AWC operations.

(8) An AWC must report to the Authority any critical incidents, abuse or suspected abuse, or neglect in accordance with OAR 410-172-0630 and OAR 309-045-0390.

(9) An AWC shall participate in Authority-led quality assurance activities, including reviews and audits.

History

Statutory/Other Authority: ORS 413.042, ORS 414.065 & Oregon Laws 2024, Ch. 37
Statutes/Other Implemented: ORS 414.065, Oregon Laws 2024, Ch. 37 & ORS 430.731
DMAP 36-2026, temporary adopt filed 08/20/2026, effective 08/20/2026 through 02/15/2027

Or. Admin. R. 410-172-0850 Telemedicine for Behavioral Health

(1) Telemedicine encompasses different types of programs, services, and delivery mechanisms for medically appropriate covered services within the recipient’s benefit package:

(a) Patient consultations using telephone and online or electronic mail (e-mail) are covered when billed services comply with the practice guidelines set forth by the Health Evidence Review Commission and the applicable HERC-approved code requirements, delivered consistent with the HERC Evidence-Based Guidelines;

(b) Patient consultations using videoconferencing, a synchronous (live two-way interactive) video transmission resulting in real time communication between a provider located in a distant site and the recipient being evaluated and located in an originating site, is covered when billed services comply with the billing requirements stated below.

(2) Behavioral health services specifically identified as allowable for telephonic delivery are listed on the Behavioral Health Fee schedule published by the Authority.

(3) Unless expressly authorized in OAR 410-120-1200 (Exclusions), other types of telecommunications are not covered such as images transmitted via facsimile machines and electronic mail when:

(a) Those methods are not being used in lieu of videoconferencing, due to limited videoconferencing equipment access; or

(b) Those methods and specific services are not specifically allowed pursuant to the Oregon Health Evidence Review Commission’s Prioritized List of Health Services and Evidence Based Guidelines.

(4) Providers billing for covered telemedicine services shall:

(a) Comply with HIPAA and the Authority’s Confidentiality and Privacy Rules and security protections for the patient in connection with the telemedicine communication and related records;

(b) Obtain and maintain technology used in the telemedicine communication that is compliant with privacy and security standards in HIPAA and the Authority’s Privacy and Confidentiality Rules set forth in OAR 943 division 14;

(c) Ensure policies and procedures are in place to prevent a breach in privacy or exposure of patient health information or records (whether oral or recorded in any form or medium) to unauthorized individuals;

(d) Comply with the relevant HERC evidence-based guidelines for telephone and e-mail consultation. Refer to the current prioritized list and evidence based guidelines at http://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Prioritized-List.aspx;

(e) Maintain clinical and financial documentation related to telemedicine services as required in OAR 410-120-1360.

(5) For purposes of behavioral health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 67-2018, minor correction filed 05/25/2018, effective 05/25/2018
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15

Or. Admin. R. 410-172-0860 Billing for Dual Eligible Individuals

(1) As described in OAR 410-120-1280 (8), when an individual has both Medicare and coverage through Medicaid, providers shall make reasonable efforts to obtain payment from other resources including Medicare or other Third Party Liability (TPL).

(2) In accordance with OAR 410-120-1280 (f), OAR 410-141-0420, and OAR 410-141-3420, behavioral health providers may bill the Division directly and may not be required to bill Medicare under the following circumstances:

(a) For behavioral health services that are never covered by Medicare or another insurer;

(b) For behavioral health services that are not covered when rendered by the following provider types:

(A) Qualified Mental Health Professional (non-licensed) as defined in OAR 309-019-0105;

(B) Qualified Mental Health Associate as defined in OAR 309-019-0105;

(C) Professional Counselor or Marriage and Family Therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists;

(D) Certified Peer Support Specialist as defined in OAR 950-060-0010;

(E) Recovery Assistant;

(F) Certified Alcohol and Drug Counselor.

History

Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
DMAP 106-2024, minor correction filed 06/11/2024, effective 06/11/2024
DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15

Division 173 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION

Or. Admin. R. 410-173-0000 Purpose

(1) These rules ensure eligible Individuals served by the Oregon Health Authority (Authority), Health Systems Division (Division), have access to 1915(i) Home and Community Based State Plan Option services that are not defined in other rules in this chapter. These rules describe services intended to increase an Individual’s independence, empowerment, dignity, and human potential through the provision of person-centered and directed, flexible, efficient, appropriate, and cost-effective services.

(2) Services described in these rules include:

(a) Home and Community Based Services (HCBS);

(b) Community Based Integrated Supports (CBIS);

(d) Psychosocial Rehabilitation for Persons with Chronic Mental Illness (PSR);

(e) Housing Support Services;

(f) Home Delivered Meals.

(3) Services described in this rule should improve eligible Individuals’ access to the greater community to the same degree as individuals who do not require services and supports to remain in their home or community;

(4) Payments for the services outlined in these rules are limited to the lowest possible cost that meet the Individual's assessed needs. Payments are not intended to replace existing supports;

(5) Medicaid is a payer of last resort. All other payment sources shall be billed prior to billing Medicaid for services.

History

Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 427.104 & 430.662
Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 427.007, 430.610, 430.620 & 430.662 – 430.670
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0005 Temporary rule language in effect until 02/15/2027. Definitions

The defined terms listed in this rule apply to all of the administrative rules included in chapter 410, division 173, 1915(i) Home and Community Based Services State Plan Option.

(1) "Activities of Daily Living (ADL)" has the meaning provided in OAR 410-172-0600.

(2) “Adult Foster Home (AFH)” means any home licensed by the Division in which residential care is provided to five (5) or fewer Individuals who are not related to the Provider by blood or marriage as described in ORS 443.705 through 443.825. If an adult family member of the provider receives care, they shall be included as one of the Individuals within the total license capacity of the AFH. An AFH or Individual that advertises, including word-of-mouth advertising, to provide room, board, and care and services for adults is considered an AFH.

(3) "Agency with Choice (AWC)" means an organization licensed by the Oregon Health Authority in accordance with OAR chapter 309, division 45 that provides Agency with Choice services.

(4) "Agency with Choice Services" means personal care and other related services provided to an individual by an Agency with Choice in accordance with this division and OAR chapter 309, division 45.

(5) “Aging and People with Disabilities (APD)” has the meaning provided in OAR 410-120-0000.

(6) "Alternative Service Resources" means other resources for the provision of services to meet an Individual's needs. Alternative service resources include but are not limited to natural supports or other community supports. Alternative service resources are not paid by Medicaid and shall be identified through the person-centered planning process. When possible, alternative service resources shall be used in lieu of Medicaid paid supports.

(7) "Assistance" has the meaning provided in OAR 410-172-0776.

(8) “Assisted Living Facility (ALF)” means a building, complex, or distinct part thereof, consisting of fully, self-contained, individual living units where six (6) or more seniors and adult Individuals with disabilities may reside in homelike surroundings. The assisted living facility offers and coordinates a range of supportive services available on a 24-hour basis to meet the activities of daily living, health, and social needs of the residents as described in these rules. A program approach is used to promote resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, and independence.

(9) “Authority” has the meaning provided in 410-120-0000.

(10) "Authorized Representative" means any adult with longstanding involvement in assuring the Individual's health and safety, appointed by the Individual, or as applicable, the Individual’s Guardian or Health Care Representative (as each term defined below in this rule) to participate in service planning process, and is:

(a) Not a paid provider of Home and Community Based Services (HCBS), and supports;

(b) Authorized, in writing or other method that clearly indicates consenting choice, by the Individual or, as applicable, Guardian or Health Care Representative, if applicable, to serve as the Individual’s representative in connection with the provision of funded supports; and

(c) Responsible to act as the authorized representative until the Individual, or as applicable, the Individual’s Guardian or Health Care, if applicable, modifies the authorization or notifies the authority or authority’s contractor that the authorized representative is no longer authorized to act on their behalf.

(11) “Behavioral Health Licensed Facility” (BH Licensed) means a community-based treatment facility that meets the licensing requirements set forth by the Authority as described in chapter 309, division 35 and chapter 309, division 40.  BH licensed facilities for these rules includes Residential Treatment Facilities (RTF), Residential Treatment Homes (RTH), and Adult Foster Homes (AFH).

(12) “Chronic Mental Health Illness” means an Individual who is diagnosed by a psychiatrist, a licensed clinical psychologist, a licensed independent Practitioner as defined in ORS 426.005 or a non-medical examiner certified by OHA or ODHS as having chronic schizophrenia, a chronic major affective disorder, a chronic paranoid disorder, or another chronic psychotic mental disorder other than those caused by substance abuse.

(13) “Cognitive Impairment” means an Individual may be physically capable of performing ADL’s or IADL’s but may have limitations in performing these tasks due to remembering, learning new things, concentrating, or making decisions that affect their everyday life. Personal care services may be required because a cognitive impairment prevents an Individual from knowing when or how to carry out the task. Assistance may include cueing or supervision to support the Individual while performing the task. This does not include or replace community-based integrated support services that support the Individual to develop the skills needed to complete the task independently.

(14) “Community-Based Integrated Supports (CBIS)” means services and supports offered to Individuals who require assistance in the acquisition, retention, or improvement with life management, socialization skills and community engagement and community integration and engagement to maintain their maximum level of functioning and integration within the broader community.

(15) “Court-Imposed Restrictions” means a court order imposing requirements or restrictions on individuals under the jurisdiction of a civil or criminal court, or under the jurisdiction of the Oregon Psychiatric Security Review Board (PRSB) placed on supervision, either in lieu of incarceration or as a condition of release from prison. Individuals who received court-imposed restrictions while on probation or parole accept the court order or the court ordered entity or program as their decision-making authority for the purposes of the rules described in 410-173-0000 through 410-173-00075.

(16) “Cueing” has the meaning provided in OAR 410-172-0600.

(17) “Cultural Competence” means the provider of 1915(i) HCBS shall participate in the state’s efforts to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency, diverse cultural and ethnic backgrounds, carceral histories, disabilities, and regardless of gender, sexual orientation, or gender identity.

(18) “Cultural Consideration” means to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds, carceral histories, disabilities, and regardless of gender, sexual orientation, or gender identity.

(19) "Delegated Nursing Task" means a registered nurse (RN) authorizes a person as described in OAR 851-047-0000 who is not licensed to provide or perform a nursing task. In accordance with OAR chapter 851 division 047, the RN shall, prior to issuing written authorization of a delegated nursing task, assess a specific eligible Individual’s care needs, evaluate the person's ability to perform the specific nursing task, provide the person with education and training to perform the nursing task, and supervise and re-evaluate the Individual and the person performing the task.

(20) "Direct Support Worker (DSW)" means a person employed by an Agency with Choice who assists individuals with ADLs, IADLs, and health-related tasks identified in the individual's person-centered service plan. A Direct Support Worker is distinct from a Personal Care Attendant (PCA).

(21) “Face-to-Face” means a personal interaction where both words can be heard and facial expressions can be seen, either in person or through Telehealth services where there is a live streaming audio and video, if Medically Appropriate and Necessary. Face-to-Face could include communication methods such as Telehealth/Telemedicine, in lieu of in-person visits, in accordance with HIPAA, as directed by OHA and as chosen by the Individual. Medically Appropriate and Necessary accommodations shall be made for Individuals with disabilities including those with hearing or sight impairments. For Telehealth the following conditions must be met:

(a) The Agent performing the assessment is independent and qualified as defined in 42 CFR § 441.730 and meets the provider qualifications defined by the State, including any additional qualifications or training requirements for the operation of required information technology;

(b) The Individual receives appropriate support during the assessment, including the use of any necessary on-site support-staff;

(22) “Family Home” has the meaning provided in OAR 410-172-0600.

(23) “Fiduciary” means a guardian or conservator appointed under the provisions of ORS 125 or any other person appointed by a court to assume duties with respect to a protected person under the provisions of ORS 125.

(24) “Functional Needs Assessment” means the comprehensive assessment or reassessment conducted by the Independent Qualified Agent (IQA), that documents an Individual’s physical, mental, and social functioning that impacts an Individual’s ability to perform everyday tasks, and the Individual’s need for 1915(i) Home and Community-Based Services using Authority-approved assessment tools.

(25) “Guardian” has the meaning assigned to it in ORS 125.300 and appointed in accordance with ORS 125.305.

(26) “Group Home” has the same meaning as Oregon's Department of Human Services (ODHS) 24-hour residential setting and means a residential home, apartment, or duplex, licensed by the Department under ORS 443.410, where home and community-based services are provided to individuals with intellectual or developmental disabilities. A 24-hour residential setting is considered a provider owned, controlled, or operated residential setting.

(27) “Habilitation” means services that support an Individual to develop, maintain, or improve skills and competencies necessary to function as independently as possible to the extent as they would if they did not have a disability or chronic condition.

(28) "Hands-on" has the meaning provided in OAR 410-172-0600.

(29) “Home” has the meaning provided in OAR 410-172-0600.

(30) “Home and Community Based Services (HCBS)” means services and supports that assist eligible Individuals to remain in their home and community in accordance with the Code of Federal Regulations, approved Medicaid State Plan authorities, and Oregon Administrative Rules.

(31) “Home and Community-Based Settings (HCB Settings)” means a physical location meeting the qualities of 42 CFR §441.710(a)(1) and (2), OAR 410-173-0035, and OAR 411-004-0020 where an Individual receives HCBS.

(32) “Home Delivered Meals” means services provided to Individuals who live in their own homes, are home bound, are unable to do meal preparation, and do not have another person available for meal preparation. Provision of the home delivered meal reduces the need for reliance on paid staff during some mealtimes by providing meals in a cost-effective manner. It is an Individuals choice whether they want to receive home delivered meals, or not.

(33) “Housing Support Services” means the services determined necessary in the Person-Centered Service plan (PCSP) for an Individual to obtain and reside in an independent community setting that is tailored to the goal of maintaining an Individual’s personal health and welcome in a HCBS where the person is directly responsible for their own living expenses.

(34) “Individually Based Limitation (IBL)” means any limitation outlined in OAR 410-173-0040 due to health and safety risks. An IBL is based on specific assessed needs and only implemented with informed consent from the Individual or, as applicable, the legal representative or authorized representative of the individual, as described in these rules.

(35) “Instrumental Activities of Daily Living (IADL)” has the meaning provided in OAR 410-172-0600.

(36) “Independent and Qualified Agent (IQA)” means an entity meeting the provider qualification requirements identified in 42 CFR §441.730 and under contract with the Division who:

(a) Determines 1915(i) program eligibility initially, annually, when an individual’s circumstances or needs change significantly, or upon individual request;

(b) Provides education and technical assistance regarding HCBS and settings;

(d) Drafts, documents, regularly reviews and updates person-centered service plans;

(e) Prior authorizes HCBS Residential Services as described in these rules;

(f) Conducts quality assurance and quality improvement activities;

(g) Completes the face-to-face needs-based assessment in person; and

(h) Performs transition management.

(37) "Individual" means the Medicaid-eligible person applying for or receiving 1915(i) program services.

(38) “Informed Consent” means the service options, risks, and benefits have been explained to the Individual, legal representative, or authorized representative, in a manner that they understand, and the Individual legal representative or authorized representative have agreed to the services on or prior to the first date of service.

(39) “interRAI Community Mental Health (CMH)” means the comprehensive standardized functional needs assessment system utilized for the 1915(i) Home and Community-Based State Plan Option that is utilized to determine level of need, continued stay criteria for applicable settings, person-centered planning, strengths and preferences, and acuity-based residential rate decisions.

(40) “interRAI Addictions Supplement (AS)” means the additional InterRAI supplement form administered to Individuals who may have a history of or who are currently displaying symptoms or risk-factors for a substance use disorder to aid person-centered planning.

(41) “interRAI Forensic Supplement (FS)” means an additional supplement form administered to Individuals being assessed for 1915(i) Home and Community-Based Services State Plan Option who have a history of involvement with the criminal justice system or were referred from a jail or other similar facility. The interRAI FS provides additional information necessary for person-centered planning for Individual’s with a history of having spent time in jail or had involvement with the criminal courts.

(42) “Legal Representative” means a person who has been legally designated by court order to make financial or health care decisions for another Individual. The Legal Representative only has authority to act within the scope and limits of their authority as designated by the court or other agreement. Legal Representatives acting outside of their authority or scope shall meet the definition of Authorized Representative.

(43) “Legally Responsible Relative” means an unpaid relative of the Individual receiving 1915(i) services who by law is responsible for the support and care of another person.

(44) “Level of Care Utilization System (LOCUS)” means a single assessment instrument that uses quantifiable measures to guide assessment, level of care placement decisions, continued stay criteria for applicable settings, and clinical outcomes in a variety of settings for both mental health and addiction purposes.

(45) “Level of Service Inventory (LSI)” has the meaning provided in OAR 410-172-0705.

(46) “Local Mental Health Authority (LMHA)” has the same meaning as Community Mental Health Program (CMHP) as described in OAR chapter 309, division 014.

(47) “Medically Appropriate” has the meaning as defined in OAR 410-120-0000 and 410-172-0630.

(48) “Medically Necessary” has the meaning as defined in OAR 410-120-0000.

(49) “Natural Support" means resources and supports (e.g., relatives, friends, significant others, neighbors, roommates, or the community associates) who voluntarily provide services and supports to an Individual without the expectation of compensation. Natural Supports are identified in collaboration with the Individual and the potential Natural Support." The Natural Support is required to have the skills, knowledge, and ability to provide the needed services and supports and shall be identified within the Person-Centered Service Plan (PCSP).

(50) “Notice of Planned Action” means a written notice mailed to the Individual as described in OAR 410-120-1865 in the event an Individual’s course of treatment or covered services shall be denied, terminated, suspended, or reduced.

(51) “ODDS” means the Oregon Department of Human Services, Office of Developmental Disabilities Services.

(52) “OHP” means the Oregon Health Plan.

(53) “Oregon Department of Human Services (Department)” or “ODHS” means the agency established in ORS chapter 409, including such divisions, programs and offices as may be established therein.

(54) “Peer Support Specialist” means a certified person as defined in ORS 414.025 providing peer delivered services to an Individual or family member with similar life experience.

(55) “Person-Centered Service Plan (PCSP)” means the written document prepared by the IQA or the person-centered service plan coordinator that details the supports, desired outcomes, activities, and resources required for an Individual to achieve and maintain personal goals, health, and safety as described in OAR 410-173-0025. The PCSP shall be completed and signed prior to the Individual receiving HCBS. The PCSP is not satisfied by a document primarily prepared by a provider. PSCP must include the following:

(a) The PCSP authorizes the Medicaid services that may be rendered and claimed;

(b) The effective date of the PCSP is upon signature by the Individual, or authorized representative, the providers of services, and the IQA PCSP coordinator;

(c) Billing for services is not authorized prior to the PSCP effective date or for any services not included in the PCSP.

(56) "Person-Centered Service Plan Coordinator (PCSP Coordinator)" means the Qualified Mental Health Professional (QMHP) or licensed professional operating within the scope of their license and employed by the Division’s contracted IQA who is designated to provide service coordination and person-centered service planning with Individuals, their person-centered services planning team, and legal or authorized representative if applicable.

(57) “Person-Centered Planning Process” means the process required by 42 CFR § 441.720 and used by the IQA to develop and approve a written PCSP jointly with the Individual, their identified person-centered service planning team, and legal or authorized representative if applicable. The person-centered planning process is directed by the Individual to the maximum extent possible. The process and service plan shall meet the requirements of OAR 410-173-0025 and are based on the independent assessment of the Individual’s assessed, approved and agreed upon needs.

(58) "Provider Owned, Controlled, or Operated Residential Setting" means:

(a) The residential provider is responsible for delivering HCBS to Individuals in the setting and the provider:

(A) Owns the setting;

(B) Leases or co-leases the residential setting; or

(C) If the provider has a direct or indirect financial relationship with the property owner, the setting is presumed to be provider controlled or operated.

(b) A setting is not provider-owned, controlled, or operated if the Individual leases directly from a third party that has no direct or indirect financial relationship with the provider;

(c) When an Individual receives services in the home of a family member, the home is not considered provider-owned, controlled, or operated.

(59) “Psychosocial Rehabilitation (PSR) Services” means services that are medical or remedial and recommended by a licensed physician or other licensed practitioner to reduce impairment to an Individual’s functioning associated with the symptoms of a mental disorder or to restore functioning to the highest degree possible. PSR helps Individuals compensate for or eliminate functional deficits, environmental and interpersonal barriers, and helps Individuals integrate as an active and productive member of their family and community with the least possible professional intervention.

(60) “Qualified Mental Health Associate (QMHA)” means an individual delivering services under the direct supervision of a QMHP who meets the minimum qualifications as authorized by the Local Mental Health Authority (LMHA) or designee and specified in OAR 309-019-0125.

(61) “Qualified Mental Health Professional (QMHP)” means a Licensed Medical Practitioner (LMP) or any other individual meeting the minimum qualifications as authorized by the LMHA or designee and outlined in OAR 309-019-0125.

(62) “Recovery Assistant” means a provider who provides a flexible range of services. Recovery assistants provide face-to-face services in accordance with a service plan that enables a participant to maintain a home or apartment, encourages the use of existing natural supports, and fosters involvement in treatment, social, and community activities. A recovery assistant shall:

(a) Be at least 18 years of age;

(b) Meet the background check requirements described in OAR 950-060-0060;

(63) “Representative Payee” or “Payee” means an individual designated by the Social Security Administration to receive money payments of aid.

(64) “Residential Treatment Facility (RTF)” means a program licensed by the Division to provide services on a 24-hour basis for six (6) to sixteen (16) Individuals as described in ORS 443.400(11).

(65) “Residential Treatment Home (RTH)” means a program that is licensed by the Division and operated to provide services on a 24-hour basis for up to five (5) Individuals as defined in ORS 443.400(12).

(66) “Serious Mental Illness (SMI)” means an Individual, who has a disorder diagnosable under the current edition of the Diagnostic and Statistical Manual of Mental Disorders, excluding intellectual disabilities, neurocognitive disorders, and substance use disorders that has resulted in functional impairment which substantially interferes with or limits one or more major life activities. Major life activities include: ADLS and IADLS as defined in OAR 410-172-0600 and functioning in social, family, community, and vocational/educational contexts.

(67) “Service Need" means the level or type of support (cueing, hands-on assistance, and supervision) an individual requires from another person or equipment to complete functions or activities as independently as possible. Service need is based on the independent assessment of the Individual’s needs.

(68) “Skilled Services” means services delegated by a Registered Nurse (RN) under Oregon’s Nurse Practice Act maybe considered personal care services when the RN provides appropriate training and delegation of the listed nursing tasks in accordance with the Oregon Nurse Practice Act. (OAR chapter 851 division 047).

(69) “Therapeutic Activities” means group and generalized activity therapy as determined in the person-centered service plan, related to the care and treatment of the Individual and administered by a qualified provider to Individuals diagnosed with a behavioral health condition that result in the improvement or reduction of symptoms and are not for recreation.

(70) “Serious and Persistent Mental Illness (SPMI)” means the current DSM diagnostic criteria for at least one (1) of the following conditions, as a primary diagnosis for an adult 18 years of age or older:

(a) Schizophrenia spectrum and other psychotic disorders;

(b) Depressive disorders;

(d) Obsessive Compulsive Disorder (OCD);

(e) Post Traumatic Stress Disorder (PTSD) and Other Specified Trauma- and Stressor-Related Disorder due to cultural syndromes; or

(f) Borderline personality disorder.

(71) “Supervision” has the meaning provided in OAR 410-172-0600.

(72) “Transition Management” means the services and supports offered to an Individual to assist them transition from a residential setting to an independent living setting of their choice.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 33-2026, amend filed 07/29/2026, effective 07/31/2026
DMAP 80-2025, amend filed 10/28/2025, effective 10/28/2025
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0010 Eligibility

(1) Individuals who apply for state plan 1915(i) HCBS must be determined eligible for those services prior to receiving them.

(a) For Individuals who are not enrolled in Title XIX Medicaid at the time they apply for 1915(i) HCBS shall have their eligibility for Title XIX Medicaid determined by The Oregon Department of Human Services (Department). The Department shall complete Title XIX Medicaid determinations according to the criteria set out in OAR chapter 461, divisions 135, 140, and 155.

(A) If an individual is determined eligible for Title XIX Medicaid by the Department, they will participate in an assessment to determine eligibility for 1915(i) HCBS in accordance with section (2) of this rule.

(B) If an individual is determined not eligible for Title XIX Medicaid by the Department, they will receive a decision notice in accordance with OAR chapter 461, division 175.

(b) Individuals who are already enrolled in Title XIX Medicaid at the time they apply for 1915(i) HCBS, will participate in an assessment to determine eligibility for 1915(i) HCBS in accordance with section (2) of this rule.

(2) Eligibility for 1915(i) HCBS is established by the Individual participating in a face-to-face administration of the functional needs assessment as defined in OAR 410-173-0005. The functional needs assessment is performed by the Authority’s Independent Qualified Agent (IQA) IQA who meets the requirements of a Qualified Mental Health Professional (QMHP) as defined in OAR 410-173-0005.

(a) Telehealth or in-person meets the requirements for face-to-face and it is the Individuals choice to conduct the functional needs assessment in-person or via telehealth;

(b) Individuals who are determined eligible for 1915(i) HCBS based on a functional needs assessment performed through the telehealth option must schedule an in-person follow up meeting with the IQA within ninety (90) days of the functional needs assessment;

(c) Individuals who are determined not eligible for 1915(i) HCBS through an assessment performed in-person or through the telehealth option, shall receive a notice of ineligibility as set out in section (9) of this rule.

(3) Prior to commencing the functional needs assessment, the IQA service coordinator shall provide the Individual and any legal guardian or Authorized Representative with information regarding service eligibility, any necessary referral processes, and services and supports covered under the 1915(i) HCBS State Plan Option or other Medicaid services the Individual may be eligible for.

(a) Specifically, the IQA service coordinator shall provide education, instruction, and information about the following:

(A) The needs assessment and the person-centered planning process, and how they are conducted;

(B) The range and scope of Individual choices and options;

(D) The grievance and appeals process;

(E) The Individual’s rights, including federal and state HCBS rights;

(F) The risks and responsibilities of self-direction;

(G) Free choice of providers and service delivery models;

(H) Reassessment and review schedules;

(I) Defining goals, needs and preferences;

(J) Identifying and accessing services, supports and resources;

(K) Development of risk management agreements;

(L) Recognizing and reporting critical events, including abuse allegations; and

(M) How to access and make reasonable accommodation requests.

(b) The information above will be provided to the Individual and any legal guardian or Authorized Representative in accordance with section (4) below of this rule.

(4) All education, instruction, and information regarding 1915(i) HCBS covered services, including eligibility, authorization, assessment, and service planning processes, as well as available providers, shall be provided in a manner that can be easily understood by the Individual and any legal guardian or authorized representative. Specifically, education, instruction, and information will be provided the Individual and any legal guardian or authorized representative in:

(a) Their preferred language, including sign language;

(b) Writing or orally, or both; and

(c) Compliance with Section 1557 of the Affordable Care Act or the Americans with Disabilities Act, which includes the provision of auxiliary aids as needed.

(5) To be eligible for services under the 1915(i) HCBS, the Individual must meet, and be documented in the Individual’s file by the IQA, all of the following requirements:

(a) Be twenty-one (21) years of age or older;

(b) Has a current diagnosis of a Serious Mental Illness as defined in OAR 410-173-0005;

(c) The interRAI CMH determined that the Individual requires assistance in at least two (2) instrumental activities of daily living (IADL) due to symptoms of a mental health condition; and

(d) Requires the provision of one (1) or more 1915(i) services at least monthly.

(6) An Individual’s eligibility for 1915(i) HCBS shall be reevaluated by participating in a new functional needs assessment and updating of their PCSP, which shall be documented in the Individual’s file, in keeping with the schedule set out in OAR 410-173-0020.

(7) Reassessment shall not be requested by any person or entity without consultation and consent of the Individual or the Individual’s legal representative or authorized representative.

(8) Individuals are not eligible to receive 1915(i) HCBS when the Individual is receiving duplicate services as delivered through Medicare or other Medicaid programs, services, or other private insurance. The Individual may choose to receive services through either of those health care programs or private insurance, but they are prohibited from receiving duplicate services.

(9) If it is determined the Individual is not eligible for 1915(i) HCBS based on the functional needs assessment or any other eligibility criteria set out in section (5) of this rule, the Individual and, if applicable, their legal representative or authorized representative, shall be notified by the Authority through a Notice of Action mailed within three (3) business days after completion of their functional needs assessment. All notifications shall:

(a) Be sent through U.S. Postal Service

(b) Include information about the Individual’s right to a contested case hearing through the Office of Administrative Hearings under the Oregon Administrative Procedures Act, ORS Chapter 183, and OAR 410-120-1860 through 410-120-1865; and

(c) Include information about how to request a hearing, which may be made orally or in writing. If made in writing, the Individual may, but is not required to, use the form included in the notification.

History

Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 413.085, 414.025, 414.070, 427.104 & 430.662
Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 413.085, 414.025, 414.070, 427.007, 430.610, 430.620 & 430.662 – 430.670
DMAP 33-2026, amend filed 07/29/2026, effective 07/31/2026
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0015 Service Authorization

(1) Authorization medical appropriateness and medical necessity for Residential Habilitation are satisfied by face-to-face eligibility or re-eligibility assessments of 1915(i) HCBS State Plan Option. These services include:

(a) Completion of a Division approved functional needs assessment tools; and

(b) Documentation of the accessed need for services by the Individual in the person-centered service plan; and

(c) Agreed to in writing by the Individual, legal representative or authorized representative, providers, Case Management Entity (CME) and IQA PCSP Coordinator.

(2) HCBS and supports for persons with chronic mental illness or an SPMI shall be deemed medically appropriate and necessary by a QMHP or other licensed provider within the scope of their practice, as outlined in OAR 410-120-0000 and OAR 410-172-0630 and for which required documentation has been submitted;

(3) Once deemed medically appropriate and necessary, HCBS identified in the PCSP are authorized for as long as deemed necessary by the QMHP, but no longer than twelve (12) months;

(4) The Division may authorize payment for the type of service that meets the Individual’s assessed needs as determined by a Functional Needs Assessment and is adequately documented in the individuals PCSP. The Division or the IQA may request additional information from the provider to determine medical appropriateness and medical necessity;

(5) Required documentation for PSR services shall support the Individual's assessed need for the service request shall include:

(a) A cover sheet detailing relevant provider and recipient Medicaid numbers;

(b) Requested dates of service;

(d) The amount of service or units requested;

(e) A behavioral health assessment and service plan meeting the requirements described in OAR 309-019-0135; and

(f) Any additional clinical information supporting medical justification for the services requested.

(6) The Division or the IQA may not authorize PSR services under the following circumstances:

(a) The request received by the Division or IQA was not complete;

(b) The provider did not hold the appropriate license, certificate, or credential at the time services were requested;

(d) The provider cannot produce appropriate documentation to support medical appropriateness;

(e) The services requested are not in compliance with OAR 410-120-1260 through 1860.

(7) Retroactive payments are not allowable. The service cannot be billed until it is documented and agreed upon by appropriate parties as describe by this rule;

(8) Payment for authorized services is valid for the time-period specified on the authorization notice but may not exceed twelve (12) months from the date of service;

(9) Authorizations expire when an Individual is found to be no longer eligible for 1915(i) HCBS;

(10) Athorized HCBS services shall be subject to random, periodic utilization review and retrospective review to ensure approved, paid services meet the definition of medical appropriateness and medical necessity as outlined in OAR 410-120-0000 and OAR 410-172-0630 are consistent with the Functional Needs Assessment.

History

Statutory/Other Authority: ORS 413.042, 414.025 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 430.640, ORS 414.065, 430.705 & 430.715
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 45-2023, minor correction filed 05/25/2023, effective 05/25/2023
DMAP 41-2023, minor correction filed 05/24/2023, effective 05/24/2023
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0020 Functional Needs Assessment

(1) The IQA shall meet face-to-face with the Individual or if applicable, their legal or guardian or authorized representative and in consultation with other persons identified by the Individual, such as caregivers and healthcare providers, to complete a Functional Needs Assessment (as defined in OAR 410-173-0005), which will provide information about the Individual’s functional needs at the time of that assessment subject to the look-back windows and will enable the IQA to determine:

(a) The Individual's abilities or need for assistance with IADLs and ADLs; and

(b) The actual or predicted need for assistance from another person during the period of time that the 1915(i) HCBS may be authorized.

(2) The functional needs assessment is a standardized process that will be conducted by the IQA using one or more of the following tools:

(a) InterRAI CMH; and

(b) The interRAI Addictions Supplement (AS) if indicated; or

(3) The interRAI CMH, AS and FS each require the following data collection methods for accurate administration of the functional needs assessment:

(a) Medical record documentation review;

(b) Individual interview;

(d) Observation.

(4) Reassessments of functional needs and updating of the person-centered service plan, both of which shall be documented by the IQA in the Individual’s file, are conducted face-to-face with the individual on the following schedule:

(a) No less frequently than annually, prior to the annual 1915(i) program eligibility date, and no earlier than sixty (60) days prior to the expiration date of the current plan; or

(b) When the individual or their legal representative, if applicable, requests reassessment; or

History

Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 443.738, 427.104 & 430.662
Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 443.738, ORS 410.020, 427.007, 430.610, 430.620 & 430.622 – 430.670
DMAP 33-2026, amend filed 07/29/2026, effective 07/31/2026
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0025 Person-Centered Service Planning Process

(1) A person-centered service plan shall be developed through a person-centered service planning process that includes the following:

(a) Be completed face-to-face with the Individual to ensure the individual’s involvement and direction in the development of their PCSP;

(b) Be directed by the Individual accessing 1915(i) services and supports;

(d) Reflect the services, supports, and delivery of those services and supports in a way that is important to the Individual;

(e) Provide necessary information and support to ensure the Individual directs their PCSP process to the maximum extent possible and is enabled to make informed choices and decisions. This information and support shall include:

(A) Notification to the individual accessing 1915(i) HCBS services informing them of their right to invite others they want to attend their PCSP meeting;

(B) Notification to the Individual’s legal representative and/or authorized representative, if applicable, informing them of the right to be included in the person-centered service planning process; and

(f) Processes that are timely, responsive to changing needs, occurs at times and locations chosen by and convenient to the Individual;

(g) A review of the PCSP with the individual, and legal or authorized representative, every ninety (90) days or more often as determined by the Individual;

(h) Practices must reflect cultural considerations and values of the Individual;

(i) Use language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the Individual and, as applicable, the legal representative or authorized representative of the Individual;

(j) Include strategies for resolving disagreement within the process, including clear conflict of interest guidelines for all planning participants that include:

(A) Discussing concerns of each person-centered service planning team member and determining acceptable solutions;

(B) Supporting the Individual in arranging and conducting a person-centered service planning meeting;

(D) For Individuals living in a residential facility refer concerns to the Oregon Residential Facilities ,Ombudsperson; and

(E) For those living independently refer concerns to the Oregon Health Plan Ombuds person; and

(F) Following existing, program-specific grievance or complaint processes;

(k) Offer choices to the Individual regarding the services and supports the Individual receives and from whom and record the alternative HCBS settings that were considered by the Individual;

(L) Provide a method for the Individual or, as applicable, the legal representative or authorized representative of the Individual to request updates to the person-centered service plan for the Individual;

(m) Be conducted to reflect what is important to the Individual to ensure delivery of services in a manner reflecting personal preferences and ensuring health and welfare;

(n) Identify the strengths and preferences, service and support needs, goals, and desired outcomes of the Individual;

(o) Include individually identified goals and preferences related to relationships, greater community participation, employment, income and savings, healthcare and wellness, and education;

(p) Include risk factors and plans to minimize any identified risk factors, including:

(A) Identification of back-up plans, as needed; and

(B) Identification of procedures to follow when the primary provider is unable to deliver approved services.

(q) Results in a person-centered service plan conducted by the IQA and implemented by the provider of HCBS in the home and community settings.

(2) Person-Centered Service Plans (PCSP):

(a) The IQA documents the person-centered service plan on behalf of the Individual and provides the necessary information and supports to ensure the Individual directs the person-centered service planning process to the maximum extent possible;

(b) The person-centered service plan shall be developed and signed at least every 365 calendar days, by the Individual, the legal representative or authorized representative of the Individual, if applicable, and the IQA. Others may be included at the invitation of the Individual and, as applicable, the legal representative or authorized representative;

(c) Authorizes Medicaid services and is effective upon the date the PSCP is signed by all parties listed above and services cannot be claimed prior to the service plan effective date;

(d) To avoid conflict of interest, the PCSP may not be developed by the provider of HCBS;

(e) The written PCSP reflects:

(A) HCBS and setting options based on the needs, preferences, strengths, and desired outcomes of the Individual, and for residential settings, the available resources of the Individual for room and board;

(B) The HCBS and settings are chosen by the Individual and are integrated in, and support full access to the greater community;

(C) Opportunities to seek employment and work in competitive integrated employment settings for those Individuals who desire to work. If the Individual wishes to pursue employment, a non-disability specific setting option shall be presented and documented in the person-centered service plan;

(D) Opportunities to engage in community life, control personal resources, and receive services in the greater community to the same degree of access as people not receiving HCBS;

(E) The strengths and preferences of the Individual;

(F) The service and support needs of the Individual;

(G) The goals and desired outcomes of the Individual;

(H) The providers of services and supports, including unpaid natural supports provided voluntarily and other alternative resources;

(I) The amount, duration, and scope of services to be provided to include:

(i) Requested dates of service;

(ii) The amount of service or units requested; and

(iii) Procedure codes for each type of service;

(iiii) The name and contact information of the provider or community-based organization providing HCBS to the Individual

(J) Risk factors identified through the person-centered services planning process and measures in place to mitigate each identified risk;

(K) Individually based limitations as identified through person-centered planning that limit or restrict HCBS settings to keep the Individual and others safe from harm;

(L) Individualized backup plans and strategies;

(M) People who are important in supporting the Individual;

(N) The person responsible for monitoring the person-centered service plan including the Individual, legal representative, or authorized representative;

(O) Language, format, and presentation methods appropriate for plain and effective communication according to the needs and abilities of the Individual receiving services and, as applicable, the legal representative or authorized representative of the Individual;

(P) The written informed consent of the Individual or, as applicable, the legal representative or authorized representative of the Individual, indicating agreement with the information, supports and services identified within the PCSP;

(Q) Signatures of the Individual or, as applicable, the legal representative or authorized representative of the Individual, participants in the person-centered service planning process, providers responsible for the implementation of the PCSP, and people identified as providing natural supports within the PCSP;

(R) Provisions to prevent unnecessary or inappropriate services and supports;

(f) The Individual or, as applicable, the legal representative or authorized representative of the Individual, decides on the level of information in the person-centered service plan that is shared with providers. To effectively provide services, providers shall have access to the portion of the person-centered service plan that the provider is responsible for implementing;

(g) The PCSP is distributed to the Individual and, as applicable, the legal representative or authorized representative of the Individual, and other people involved in the person-centered service plan as described above in subsection (e) of this section;

(h) The PCSP shall justify and document any individually-based limitation as described in OAR 410-173-0040 when conditions under OAR 410-173-0035(1)(d) and (2) (d-j) may not be met due to threats to the health and safety of the individual or others

(3) The person-centered service plan shall be reviewed and revised as directed by the Individual, their legal representative or authorized representative

(a) At least annually and upon reassessment of functional needs;

(b) At the request of the Individual or, as applicable, the legal representative or authorized representative of the Individual; or

(4) The PCSP shall be signed by the Individual, and legal or authorized representative any time a revision occurs.

History

Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 414.025, 443.738 & 427.104
Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 414.025, 443.738, 410.020, 427.007, 430.610, 430.620 & 430.662 – 430.670
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0030 Qualifications for Home and Community Based Services Providers

(1) Providers of 1915(i) HCBS shall meet the following qualifications for each type of service they are providing as described in this rule and:

(a) Meet all necessary provider qualifications, including relevant experience, as outlined in: OAR chapter 309, division 019; chapter 309, division 035, division 040, OAR chapter 410, division 172; and OAR chapter 950, division 060; and

(b) Be enrolled by the Division as a Medicaid provider as outlined in OAR 410-120-1260.

(2) AFH providers shall:

(a) Be 21 years of age or older;

(b) Comply with the 1915(i) HCBS setting qualities identified in OAR 410-173-0035;

(d) Document the services as outlined in OAR 410-173-0045; and

(e) Comply with OAR Chapter 309, Division040, rules governing Adult Foster Homes.

(3) Residential Treatment Facility (RTF) and Residential Treatment Homes (RTH) providers shall:

(a) Be at least 18 years of age;

(b) Comply with the 1915(i) HCBS setting qualities identified in OAR 410-173-0035;

(d) Document the services as outlined in OAR 410-173-0045; and

(e) Comply with OAR Chapter, 309 Division 035 rules governing Residential Treatment Facilities and Residential Treatment Homes for Adults with Mental Health Disorders.

(5) Outpatient behavioral health providers of 1915(i) HCBS shall comply with the qualifications and competencies outlined in OAR 309-019-0125, 309-035-0135, 309-040-0360. Providers exempt from licensure or registration per ORS 675.090(f), 675.523(3), or 675.825(c) shall be employed by or contracted with a provider organization certified by the Authority under ORS 430.610 to 430.695 as described in OAR 410-172-0660.

(6) 1915(i) HCBS providers, as identified above, shall adhere to the following provider qualifications:

(a) Demonstrate by background, skills and abilities the capability to safely and adequately provide the services authorized, in the judgment of the Authority or its designee;

(b) Maintain a drug-free workplace: and be approved through the criminal history check process described in OAR Chapter 407, Division007 and OAR Chapter 943 Division 007;

(d) Be authorized to work or operated in the United States, in accordance with U.S. Department of Homeland Security, Bureau of Citizenship and Immigration rules;

(e) Complete criminal history background checks and re-checks in accordance with OAR Chapter 407 Division 007. A provider’s failure to complete a new criminal history check authorization shall result in the inactivation of the provider enrollment. Once inactivated, a provider must reapply and meet the standards described in this rule to have their provider enrollment reactivated; and

(f) Not be included on any US Office of Inspector General Exclusion lists.

History

Statutory/Other Authority: ORS 124.050-124.095, 409.040, 413.032, 413.042, 413.071, 413.085, 414.025, 426.500, 443.738, ORS 409.050, 427.104 & 430.662
Statutes/Other Implemented: ORS 124.050-124.095, 409.040, 413.032, 413.042, 413.071, 413.085, 414.025, 426.500, 443.738, ORS 427.007, 430.610, 430.620 & 430.662 – 430.670
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0035 Home and Community Based Services and Setting Qualities

(1) Residential and non-residential HCBS settings shall support Individuals in having the same opportunities for integration, access, choice, and rights as Individuals not accessing 1915(i) HCBS;

(2) Providers of 1915(i) HCBS shall develop, implement, and maintain policies and procedures to address the following HCBS residential and non-residential setting requirements;

(a) The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for Individuals enrolled in or receiving HCBS to:

(A) Seek employment and work in competitive integrated employment settings;

(B) Engage in greater community life;

(D) Receive services in the greater community.

(b) The residential or non-residential setting is selected by an Individual or, as applicable, the legal representative or authorized representative of the Individual, from available setting options, including non-disability specific settings and an option for a private unit in a residential setting. The setting options shall:

(A) Be identified and documented in the Individual’s person-centered service plan;

(B) Be based on the desires, needs, preferences, and strengths of the Individual;

(i) A physical emergency restraint as outlined in OARs 309-035-0105 and 309-040-0305 may be used to prevent immediate injury to an Individual who is in danger of physically harming themselves or others;

(ii) A physical emergency restraint shall use only the degree of force reasonably necessary for protection and for the least amount of time necessary;

(iii) A physical emergency restraint shall be documented and maintained in the providers records, identifying the reason for the restraint and the duration of the restraint.

(D) Optimizes, but does not regiment, individual initiative, autonomy, self-direction, and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the Individual chooses to interact; and

(E) Facilitates individual choice regarding services and supports and who provides the services and supports.

(A) Meet all the qualities in section (1) of this rule;

(B) Be physically accessible to an individual;

(C) Be a specific physical place that may be owned, rented, or occupied by an individual under a legally enforceable residency agreement. The Individual has, at a minimum, the same responsibilities, and protections from an eviction that a tenant has under the Oregon landlord tenant law. For a setting in which landlord tenant laws do not apply, the residency agreement shall provide protections for the individual and address eviction and appeal processes. The eviction and appeal processes shall be substantially equivalent to the processes provided under landlord tenant laws;

(D) Provide the Individual privacy in their own unit;

(E) Provide locks on individual doors lockable by the Individual, with the Individual and only appropriate staff having a key to the unit;

(F) Provide choice of roommates to Individuals sharing units;

(G) Provide Individuals the freedom to decorate and furnish their own unit as agreed to within the residency agreement;

(H) Allow Individuals to have visitors of their choosing at any time;

(I) Provide Individuals the freedom and support to control their own schedule and activities; and

(J) Provide Individuals the freedom and support to have access to food at any time.

(4) Providers initially licensed or certified by the Authority on or after January 1, 2016, shall meet the requirements in these rules prior to being issued a license by the Division.

(5) HCBS settings do not include the following:

(a) A nursing facility;

(b) An institution as outlined in ORS 426.010;

(d) A hospital providing long-term care services; and

(e) Any other setting that has the qualities of an institution that include:

(A) A setting located in a building that is also a publicly or privately-operated facility that provides inpatient institutional treatment;

(B) A setting located in a building on the grounds of or immediately adjacent to a public institution;

(D) A non-residential setting that isolates individuals from the greater community.

(6) A setting that is presumed to have the qualities of an institution, as outlined in section (5) of this rule, shall be subject to a heightened scrutiny process. The setting shall have the opportunity to deny the presumption by submitting evidence of their compliance with these rules. Upon review of the evidence, if the Division determines:

(a) A setting has not overcome the presumed qualities of an institution, 1915(i) funding may not be used; or

(b) A setting has provided adequate evidence to rebut the presumption that it has the qualities of an institution, the Division shall submit the evidence to the federal Centers for Medicare and Medicaid Services (CMS) after a 30-day public comment period. If CMS determines that a setting has not overcome the presumed qualities of an institution, 1915 (i)HCBS funding may not be used.

History

Statutory/Other Authority: ORS 409.040, 409.050, 413.032, 413.042, 413.071, 413.085, 426.500, 443.738, ORS 409.050, 427.104 & 430.662
Statutes/Other Implemented: ORS 409.040, 409.050, 413.032, 413.042, 413.071, 413.085, 426.500, 443.738, ORS 427.007, 430.610, 430.620 & 430.662 - 430.670
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0040 Individually Based Limitations

(1) When certain HCBS setting qualities may not be met due to a threat to the health and safety of an Individual or others, a provider shall submit a request for an Individually-based limitation (IBL) to the IQA;

(2) An IBL shall be supported by a specific assessed need and documented in the PCSP. The IQA shall complete a Division-approved form documenting the IBL. The form identifies and documents, at a minimum, the following requirements:

(a) The specific and individualized assessed need justifying the IBL;

(b) The positive interventions and supports used prior to any IBL;

(d) A clear description of the limitation that is directly proportionate to the specific assessed need;

(e) Regular collection and review of data to measure the ongoing effectiveness of the IBL;

(f) Established time limits for periodic reviews of the IBL to determine if the limitation shall be terminated or remains necessary;

(g) The informed consent of the Individual or, as applicable, the legal representative of the individual, including any discrepancy between the wishes of the Individual and the consent of the legal representative, as evidenced by a signature and date;

(h) An assurance that the interventions and support do not cause harm to the Individual; and

(i) Documentation that the IBL shall be reviewed on a timeframe agreed upon by the PCS planning team at least every twelve (12) months.

(3) Providers are responsible for:

(a) Maintaining a copy of the completed and signed form documenting the consent to the appropriate limitation. The form shall be signed by the Individual, or, if applicable, the legal or authorized representative of the individual;

(b) Regular collection and review of data to measure the ongoing effectiveness of and the continued need for the individually based limitation; and

(c) Requesting a review of the individually- based limitation when a new individually-based limitation is indicated, or a change or removal of an individually based limitation is needed.

History

Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 443.738, ORS 430.021, 430.735, 426.072 & 443.739
Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 443.738, ORS 427.007, 430.610, 430.620 & 430.662 - 430.670
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0045 Service Reimbursement Documentation Standards

(1) All Providers rendering 1915(i) HCBS are required to maintain records that fully support the extent of services (i.e. scope, amount, and duration) for which payment is requested and provide the records to either or both the Division and IQA upon request.

(2) All records shall comply with documentation standards set out in OAR 410-120-1360 and 410-172-0620. For the purpose of clarity, all documentation of services provided must include all of the following:

(a) The name of the Individual receiving 1915(i) HCBS;

(b) The Medicaid Identification Number of the Individual receiving 1915(i) HCBS;

(d) Type of service and supports provided, which must be identified and described in the PCSP and all of the following relating to the type of service provided;

(e) Date of service;

(f) Start time of each service; and

(g) End time of each service.

(3) All providers shall also document how the services and supports relate to identified goals and objectives outlined in the PCSP.

(4) Providers shall document how the services and supports addressing the following HCBS qualities:

(a) Employment and volunteer opportunities;

(b) Individual choice of community activities and community access;

(d) Strategies identified in the PCSP to ensure the health and safety of the individual or others.

(5) All Medicaid 1915(i) HCBS provided in a person’s own, or family home must be documented or otherwise verified using an Electronic Visit Verification (EVV) system, as required under Section 1903 of the Social Security Act. EVV systems shall electronically verify the following information at the time the service is occurring:

(a) Type of service performed;

(b) Individual receiving the service;

(d) Individual providing the service; and

(e) Time the service begins and ends.

(6) The information that all providers must include in their records, including the individual’s records, shall be appropriate in quality and quantity to meet the professional standards applicable to the provider and any additional, applicable standards for documentation that are identified in OAR Chapters 410 and 309, the Medicaid provider enrollment agreement submitted to OHA, and any other applicable contracts.

History

Statutory/Other Authority: ORS 124.050 - 124.095, 163.275 & 443.765
Statutes/Other Implemented: ORS 124.050 - 124.095, 163.275 & 443.765
DMAP 33-2026, amend filed 07/29/2026, effective 07/31/2026
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0050 HCBS Community Based Integrated Supports

(1) Community-Based Integrated Supports (CBIS) are services and supports offered to Individuals that require assistance in the acquisition, retention, or improvement with life management, socialization skills and community engagement and community integration and engagement to maintain their maximum level of functioning and integration within the broader community, to the same degree as Individuals who do not access Medicaid 1915(i) CBIS. These services are provided face-to-face as chosen by the Individual and as described and approved in the Individual’s PCSP and include:

(a) Supervision, support, training, and assistance necessary for an individual to develop, maintain or improve skills and competencies necessary to function as independently as possible in the following areas:

(A) Independent living skills

(B) Behavior management skills;

(D) Financial literacy;

(E) Social skills;

(F) Communication skills;

(G) Therapeutic activities; and

(H) Community integration, access and inclusion.

(b) Home and Community-Based skill reintegration service. These services support and individual to re-build the skills and complete tasks for themselves rather than completing the task for an individual;

(c) Case management, service coordination, peer delivered services programs, and programs and resources managed by the IQA and directed by the individual through person-centered service planning, to include:

(A) Identification of back-up plans as needed to mitigate health and safety risks to the individual or others; and

(B) Identify procedures to follow when the primary provider is unable to deliver approved services.

(2) CBIS are delivered consistent with the amount, duration, and scope of services identified in the PCSP, demonstrated through documentation as identified in OAR 410-173-0045.

(3) CBIS shall be provided in the following settings, as identified in the PCSP:

(a) Community;

(b) Individual's own or family home.

(4) CBIS shall be provided by the following provider types who meet the qualifications defined in OAR Chapter 309 Division 019, OAR Chapter 410 Division 172, or OAR Chapter 950 Division 060:

(a) RTH providers;

(b) RTF providers;

(d) QMHA;

(e) Recovery Assistant or Mentor;

(f) Certified Peer Support Specialist or Peer Wellness Specialist, including family and youth support and wellness specialists, meeting the qualifications described in OAR chapter 309 division 019 and shall meet the requirements in OAR chapter 950 division 060 for certification and continuing education; and

(g) Mental Health Intern.

(5) Provision of CBIS is allowed for eligible Individuals who are being temporarily served in an acute care hospital setting to enable direct care workers or other home and community-based providers to accompany Individuals to acute care hospital setting;

(a) CBIS shall be focused on providing personal, behavioral and communication supports not otherwise provided in an acute care hospital;

(b) The service may only be delivered in the acute care hospital setting for up to thirty (30) days;

(d) Provided to meet needs of the Individual that are not met through the provision of hospital services;

(e) Not be a substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and

(f) Designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the Individual’s functional abilities.

History

Statutory/Other Authority: ORS 413.032, 413.042, 426.495, 430.610 & 430.630
Statutes/Other Implemented: ORS 413.032, 413.042, 426.495, 430.610 & 430.630
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 44-2023, minor correction filed 05/25/2023, effective 05/25/2023
DMAP 42-2023, minor correction filed 05/24/2023, effective 05/24/2023
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0055 Eligibility Criteria for Community Based Integrated Supports

(1) To be eligible for CBIS defined in this rule, Individuals shall:

(a) Be eligible for 1915(i) HCBS as outlined in OAR 410-173-0010

(b) Have identified needs for assistance with ADLs or IADLs requiring services and supports in the home and community that natural supports are unable to provide; and

(2) Individuals determined eligible to receive CBIS shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided. The Individual’s choice shall be reflected by their signature, or, if appropriate, the legal or authorized representative’s signature of informed consent on the Individual’s PCSP.

(3) These services cannot duplicate services received though other authorities.

History

Statutory/Other Authority: ORS 413.042, 426.495, 430.610 & 430.630
Statutes/Other Implemented: ORS 413.042, 426.495, 430.610 & 430.630
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0060 HCBS Residential Habilitation

(1) HCBS Residential Habilitation Services are designed to assist and support an Individual to maintain, reacquire, or improve skills and functioning in ADL and IADL due to the symptoms of a behavioral health condition;

(2) HCBS Residential Habilitation shall include supervision, support, training, and assistance necessary for an Individual to develop, maintain or improve skills and competencies necessary to function as independently as possible and to the same degree as Individuals who do not access 1915(i) HCBS in the following areas:

(a) Behavior management skills;

(b) Financial literacy;

(d) Communication skills;

(e) Therapeutic activities;

(f) Community integration access, and inclusion; and

(g) Community navigation skills.

(3) Case management, service coordination, peer delivered services programs, and programs and resources managed by the IQA and directed by the Individual through person-centered service planning, to include:

(a) Identification of back-up plans as needed to mitigate health and safety risks to the Individual or others; and

(b) Identify procedures to follow when the primary provider is unable to deliver approved services.

(4) Nurse delegation tasks may be delivered as identified on the Individual’s PCSP and as defined in OAR 410-173-0005, OAR 309-035-0105 and OAR 309-035-0215. Skilled services delegated by a Registered Nurse (RN) under Oregon’s Nurse Practice Act may be considered personal care services and included in HCBS Residential Habilitation when the RN provides appropriate training and delegation of the listed nursing tasks in accordance with the Oregon Nurse Practice Act (OAR Chapter 851 Division 047);

(5) Completing ADL or IADL or nurse delegation tasks includes a range of assistance, based on assessed need, provided to Individual’s with disabilities and chronic conditions that enables them to accomplish ADL/IADL tasks they would normally do for themselves if they did not have a disability or chronic condition. Assistance may be in the form of hands-on assistance, supervision and/or cueing;

(6) HCBS Residential Habilitation Services shall be provided in the following settings, as identified in the PCSP:

(a) Community;

(b) OHA BH licensed RTF- not Secured Residential Treatment Facilities;

(d) OHA, BH licensed AFH;

(e) ODHS, APD licensed AFH;

(f) ODHS, ODDS licensed AFH;

(g) ODHS, APD licensed RCF;

(h) ODHS, APD licensed ALF;

(i) ODHS, ODDS certified Group Care Homes and State Operated Group Homes for Adults.

(7) HCBS Residential Habilitation Services shall be provided by the following provider types: who meet the qualifications defined in OAR chapter 309 division 019, OAR chapter 410 division172, or OAR chapter 950 division060:

(a) OHA licensed AFH providers meeting the qualifications described in OAR chapter 309 division 040;

(b) OHA licensed RTH providers meeting the qualifications described in OAR chapter 309 division 035;

(d) ODHS, APD licensed Adult Foster Homes meeting qualification described in OAR 411 division 050;

(e) ODHS, ODDS licensed Adult Foster Homes meeting qualification described in OAR chapter 411 division 360;

(f) ODHS, APD licensed Residential Care Facilities meeting qualifications described in OAR chapter 411 division 054;

(g) ODHS, APD licensed Assisted Living Facilities meeting qualifications described in chapter 411 division 054; or

(h) ODHS, ODDS certified Group Care Homes and State Operated Group Homes for Adults meeting qualifications described in OAR chapter 411 division 325;

(i) QMHP;

(j) QMHA;

(k) Recovery Assistant or Mentor;

(L) Certified Peer Support Specialist; or

(m) Mental Health Intern.

(8) Payment does not include the cost of room and board.

History

Statutory/Other Authority: ORS 413.032, 413.042, ORS 411.025, ORS 426.495, 430.610 & 430.630
Statutes/Other Implemented: ORS 413.032, 413.042, ORS 426.495, 430.610 & 430.630
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 43-2023, minor correction filed 05/24/2023, effective 05/24/2023
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0065 Eligibility Criteria for HCBS Residential Habilitation

(1) To be eligible for HCBS Residential Habilitation Services defined in this rule, Individuals shall:

(a) Be eligible for 1915(i) HCBS per OAR 410-173-0010;

(b) Have assessed needs for HCBS Residential Habilitation Services requiring services and supports in the home and community that natural supports are unable to consistently provide;

(2) Individuals determined eligible to receive HCBS Residential Habilitation Services shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided. The Individual’s choice shall be reflected by their signature, or, if appropriate, the legally authorized representative, or authorized representative’s signature of informed consent;

(3) These services cannot duplicate services received though other authorities.

History

Statutory/Other Authority: ORS 413.042, 426.495, 430.630 & 430.640
Statutes/Other Implemented: ORS 413.042, 426.495, 430.630 & 430.640
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0070 HCBS Psychosocial Rehabilitation for Persons with Chronic Mental Illness

(1) Psychosocial Rehabilitation (PSR) services shall be identified and agreed upon within the PCSP and shall:

(a) Support the desires and goals of the Individual receiving services;

(b) Increase the independence of the Individual receiving PSR;

(d) Maintain the health and safety of the Individual and others in the home or community.

(2) PSR services shall be provided face-to-face as defined in these rules and as chosen by the Individual and supported by the Individual’s needs. PSR services are identified, and agreed to by the Individual, including the amount, frequency, duration and scope of services in the PCSP, as appropriate in the amount, frequency, duration, modality, and scope of services identified and approved in the Individual’s PCSP, and include the following:

(a) Comprehensive medication services as prescribed by an LMP;

(b) Individual therapy;

(d) Family therapy;

(e) Psychiatric skills training;

(f) Behavioral health counseling therapy;

(g) Psychiatric activity therapy or community psychiatric supportive treatment; and

(h) Assertive community treatment as described in OAR 309-019-0225 through 309-019-0255.

(3) PSR services shall be consistent with the following:

(a) Evidence-based or evidence-informed practices; and

(b) The amount, frequency, duration, and scope of services delivered as identified in the PCPS.

(4) PSR services shall be provided in the following settings, as identified within the PCSP, and provided by appropriate provider types identified in (5) of this rule :

(a) Community;

(b) Individuals own or family home;

(d) OHA licensed RTH;

(e) OHA licensed RTF;

(f) ODHS, APD licensed Adult Foster Homes;

(g) ODHS, ODDS licensed Adult Foster Homes;

(h) ODHS, APD licensed Residential Care Facilities that are not considered secure;

(i) ODHS, APD licensed Assisted Living Facilities; or

(j) ODHA, ODDS certified Group Care Homes and State Operated Group Homes for Adults.

(5) PSR services shall be provided by the following provider types who meet the qualifications defined in OAR chapter 309 division 019, OAR chapter 410 division 172, or OAR chapter 410 division180:

(a) LMP;

(b) QMHP;

(d) Mental Health Intern; or

(e) Behavioral health organization certified by the Authority under ORS 430.610 to 430.695.

(6) Provision of PSR is allowed for eligible Individuals who are being temporarily served in an acute care hospital setting to enable direct care workers or other home and community-based providers to accompany Individuals to acute care hospital setting;

(a) These services shall be focused on providing personal, behavioral and communication supports not otherwise provided in an acute care hospital;

(b) The service shall only be delivered in the acute care hospital setting for up to thirty (30) days;

(d) Provided to meet needs of the Individual that are not met through the provision of hospital services;

(e) Not be a substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and

(f) Designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the Individual’s functional abilities.

(7) Psychosocial rehabilitation services under the 1915(i) differ in nature, scope, supervision arrangements, and provider type (including provider training and qualifications) from psychosocial rehabilitation services otherwise available.

History

Statutory/Other Authority: ORS 413.032, 413.042, 426.495, 430.630 & 430.640
Statutes/Other Implemented: ORS 413.032, 413.042, 426.495, 430.630 & 430.640
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0075 Eligibility Criteria for HCBS Psychosocial Rehabilitation for Persons with Chronic Mental Illness

(1) To be eligible for PSR services outlined in these rules, Individuals shall:

(a) Be eligible for 1915(i) HCBS as outlined in OAR 410-173-0010 and

(b) Have assessed needs for PSR requiring services and supports in the home and community;

(2) Individuals determined eligible to receive PSR shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided to meet the Individual’s assessed needs. The Individual’s choice shall be reflected by their signature, or, if appropriate, the legal or authorized representative’s signature indicating informed consent.

(3) These services cannot duplicate services received through other authorities-Medicaid, Medicare, or other medical coverage.

History

Statutory/Other Authority: ORS 413.042, 426.495, 430.630 & 430.640
Statutes/Other Implemented: ORS 413.042, 426.495, 430.630 & 430.640
DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019
DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019

Or. Admin. R. 410-173-0080 Housing Support Services

(1) HCBS Housing Support Services shall be provided to Individuals as determined medically necessary and appropriate for an Individual to obtain and reside in an independent community setting and are tailored to the goal of maintaining an Individual’s personal health and welfare in a HCB setting where an Individual is responsible for their living expenses.

(2) Housing support services may include one or more of the following individual housing and tenancy sustaining services:

(a) Coordination with the Individual to plan, participate in, review, and modify their individualized housing support plan on a regular basis, including redetermination and/or planning meetings, to reflect current needs and preferences, and address existing or recurring housing retention barriers;

(b) Provide assistance with securing and maintaining entitlements and benefits (including rental assistance) necessary to maintain community integration and housing stability (e.g., assisting Individuals in obtaining documentation, assistance with completing documentation, navigating the process to secure and maintain benefits, and coordinating with the entitlement/benefit assistance agency;

(d) Monitoring and follow-up to ensure that linkages are established, and services are addressing housing needs;

(e) Providing supports to assist the Individual in the development of independent living skills to remain in the most integrated setting;

(A) Skills coaching to maintain a healthy living environment;

(B) Skills coaching to develop and manage a household budget;

(D) Skills coaching to reduce social isolation;

(E) Skills coaching to utilize local transportation.

(f) Provide supports to assist the Individual in communicating with the landlord and/or other property manager;

(g) Education and training on the roles, rights, and responsibilities of the tenant and landlord;

(h) Provide training and resources to assist the Individual with complying with his/her lease;

(i) Assisting the Individual to reduce the risk of eviction by providing services to prevent eviction (e.g.; to improve conflict resolution skills, coaching, role-playing and communication strategies targeted towards resolving disputes with landlords and neighbors; communicating with landlords and neighbors to reduce the risk of eviction; addressing biopsychosocial behaviors that put housing at risk; providing ongoing support with activities related to household management; and linking the tenant to community resources to prevent eviction);

(j) Providing early identification and intervention for actions or behaviors that may jeopardize housing;

(k) Assistance with connecting the Individual to expert community resources to address legal issues impacting housing and thereby adversely impacting health, such as assistance with breaking a lease due to unhealthy living conditions.

(3) Housing support services may not include:

(a) Payment of ongoing rent or other room and board cost;

(b) Capital costs related to the development or modification of housing;

(d) Goods or services intended for leisure or recreation

(e) Duplicative services from other state or federal programs ;

(4) Housing support services shall be provided by the following provider types meeting all the rule requirements as an enrolled qualified Medicaid provider under OAR 407-120-0300 through 0400 and OAR 410-120-1260:

(a) Housing supports providers shall meet the following qualifications and competencies:

(A) A degree in a human/social services field or a relevant field or at least one year of relevant professional experience and/or training in the field of service; and

(B) Knowledge of principles, methods, and procedures of services included under housing support services, or comparable services meant to support activities to assess need, arrange for, and procure needed housing resources.

(b) General business contractors, includes retail/online stores, property managers, utility companies, shall meet the following qualifications and competencies:

(A) Any required license, certification or other state required standard to operate the type of business relevant to the item or service being requested. For example, payments for utilities must be made to a utility provider that is authorized to operate in the State of Oregon. The utility provider maintains all appropriate licenses, certifications, etc. to operate as a utility provider in the State. Providers completing necessary home accessibility adaptions must be licensed, bonded, insured; and

(B) Hold a current Construction Contractors Board (CCB) license.

(c) Self-employed registered nurses holding a current Oregon State Board of Nursing license practicing under the standards and scope of practice for licensed nurses.

(5) Be committed to cultural responsiveness training and language accessibility to ensure equity in service delivery.

History

Statutory/Other Authority: ORS 413.042, 426.495, 430.630 & 430.640
Statutes/Other Implemented: ORS 413.042, 426.495, 430.630 & 430.640
DMAP 42-2024, adopt filed 02/14/2024, effective 02/29/2024

Or. Admin. R. 410-173-0085 Eligibility for Housing Support Services

(1) To be eligible for Housing Support Services outlined in these rules, Individuals shall:

(a) Be eligible for 1915(i) Housing Support Services be outlined in these rules or OAR 410-173-0010;

(b) Have assessed needs for Housing Support Services as approved and documented in the PCSP;

(2) Individuals determined eligible to receive Housing Support Services shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided to meet the individual’s assessed needs. The individual’s choice shall be reflected by their signature, or, if appropriate, the legal or authorized representative’s signature indicating informed consent.

(3) These services cannot duplicate services received though other authorities.

History

Statutory/Other Authority: ORS 413.042, 426.495, 430.630 & 430.640
Statutes/Other Implemented: ORS 413.042, 426.495, 430.630 & 430.640
DMAP 42-2024, adopt filed 02/14/2024, effective 02/29/2024

Or. Admin. R. 410-173-0090 Home Delivered Meals

(1) 1915(i) home delivered meals shall be provided to eligible Individuals who are home bound, live in their own home, and are unable to complete meal preparation, to assist an Individual to remain in their own home and are intended to provide one (1) meal per day;

(2) Home delivered meal services shall be provided in the following settings, as identified, and approved within the PCSP:

(a) Community; or

(b) Individuals own or family home.

(3) Home delivered meals are not available to Individuals residing in a setting in which residential providers are responsible to provide meals.

History

Statutory/Other Authority: ORS 410.070, ORS 411.060 & 411.070
Statutes/Other Implemented: ORS 410.070
DMAP 42-2024, adopt filed 02/14/2024, effective 02/29/2024

Or. Admin. R. 410-173-0095 Eligibility for Home Delivered Meals

(1) To be eligible for 1915(i) home delivered meals and Individual must:

(a) Be 1915(i) HCBS as outlined in OAR 410-173-0010 eligible;

(b) Have assessed needs for Home Delivered Meals as documented and approved in the PCSP;

(d) Not have natural supports available that are willing and able to provide meal preparation services;

(2) Individuals determined eligible to receive Home Delivered Meals shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided to meet the individual’s assessed needs. The Individual’s choice shall be reflected by their signature, the Individual’s legal or authorized representative’s, signature.

(3) These services cannot duplicate services received though other authorities.

History

Statutory/Other Authority: ORS 410.070, ORS 411.060 & 411.070
Statutes/Other Implemented: ORS 410.070
DMAP 42-2024, adopt filed 02/14/2024, effective 02/29/2024

Or. Admin. R. 410-173-0100 Provider Qualifications for Home Delivered Meals

(1) To be in alignment with the provision of services, home delivered meal providers must have contracts with, or be, an Area Agency on Aging or AAA as defined in 411-002-0100(1).

(2) The provider must be in compliance, during all stages of food service operation, with applicable federal, state, and local regulations, codes, and licensure requirements relating to fire, health, sanitation, safety, building and other provisions relating to the public health, safety, and welfare of meal patrons.

(3) The provider must demonstrate that menu standards are developed to sustain and improve a participant’s health through the provision of safe and nutritious meals that are approved by a dietician.

(4) Each provider must be an enrolled Medicaid provider approved to provide Medicaid home delivered meals.

(5) The provider must ensure that all requirements in OAR 411-040-0035 through 411-040-0037 are met.

(6) Providers must ensure that anyone who delivers meals:

(a) Have passed a background check as defined in OAR 407-007-0275; or

(b) Uses an approved carrier.

(7) All requests for Medicaid home delivered meals received by the provider must be referred to the Department or the Medicaid AAA office for prior authorization.

(8) Meal providers must not solicit program income or voluntary donations from Medicaid eligible participants.

History

Statutory/Other Authority: ORS 410.070, ORS 411.060 & 411.070
Statutes/Other Implemented: ORS 410.070
DMAP 42-2024, adopt filed 02/14/2024, effective 02/29/2024

Or. Admin. R. 410-173-0105 Temporary rule language in effect until 02/15/2027. 1915(i) In-Home Personal Care

(1) Except as otherwise provided in this division, OARs 410-172-0774 through 410-172-0845 apply to 1915(i) In-Home Personal Care (IHPC) services authorized under this division to ensure services are administered in a consistent and equitable manner, except where this division provides otherwise.

(a) For purposes of applying OARs 410-172-0776 and 410-172-0800 through 410-172-0845 to 1915(i) IHPC services:

(A) References to a person-centered service plan (PCSP) apply only to the portions of an individual's 1915(i) PCSP authorizes 1915(i) IHPC services.

(B) References to a service coordinator include the Authority's Independent Qualified Agent (IQA) responsible for assessment, service authorization, person-centered service planning, monitoring, or related 1915 (i)IHPC functions under this division.

(C) References to the State Plan Personal Care (SPPC) program means 1915(i) IHPC services authorized under this division.

(b) Eligibility determination, assessment, service authorization, and person-centered service planning for 1915(i) IHPC services are governed by this division.

(d) Nothing in this rule is intended to conflict with or supersede any applicable collective bargaining agreement (“CBA”) governing homecare workers (as defined in ORS 410.600(9)), personal support workers (as defined in ORS 410.600(12)), personal care attendants (as defined in OAR 418-020-0010), or direct support workers (as defined in ORS 443.360). In the event of a conflict, applicable state or federal law controls. To the extent permitted by law, the terms of the applicable CBA also control over this rule.

(2) 1915(i) IHPC services support eligible individuals to meet their assessed personal care needs and live in the community, and:

(a) Are authorized for eligible individuals who have received a functional needs assessment and PCSP from the Authority’s Independent and Qualified Agent (IQA) that identifies the 1915(i) IHPC necessary to the individual’s assessed needs;

(b) Are provided in a manner that allows an eligible individual to direct their services and supports;

(c) Assist individuals with Activities of Daily Living (ADL) or Instrumental Activities of Daily Living (IADL) tasks, as defined in OAR 410-173-0005; and

(d) Exclude services whose primary purpose is the acquisition, retention, and improvement of the skills needed to accomplish ADL/IADL tasks.

(3) The Authority has established task-specific maximum service period hours for HCBS 1915(i) IHPC services based on an individual's assessed need for assistance with ADLs and IADLs.

(4) Individuals who receive HCBS 1915(i) IHPC services may receive their services through one of two service delivery models:

(a) PCA model with consumer-employer responsibilities as described in OAR 410-172-0800; or

(b) Agency with Choice model with co-employer responsibilities as described in OAR chapter 309, division 45.

(5) Regardless of the service delivery model, individuals receiving 1915(i) IHPC services retain authority to direct their services by:

(a) Identifying candidates for employment;

(b) Screening otherwise qualified candidates to determine their ability to meet the individual's assessed needs;

(d) Participating in the selection and dismissal of workers in accordance with the applicable service delivery model.

(6) Employer responsibilities vary by service delivery model as follows:

(a) Under the PCA model, the individual serves as the consumer-employer and hires, supervises, and dismisses PCAs in accordance with OAR 410-172-0800.

(b) Under the Agency with Choice (AwC) model, the Agency with Choice serves as the common-law employer including answering questions and providing support for DSW hiring, supervision and conduct. The individual retains authority to direct day-to-day services and participates in the selection and dismissal of DSWs.

(7) The Authority may terminate a PCA provider as described in OAR 410-172-0820.

(8) ADLs include eating, bathing, dressing, toileting, maintaining continence, mobility and transferring:

(a) Eating includes assisting the individual in feeding or fluid intake by any means from a receptacle into the body including gastrostomy tubes, including monitoring to prevent choking or aspiration;

(b) Bathing includes assisting the individual with cleansing the body, washing hair, and using assistive devices when necessary to get in and out of the bathtub or shower;

(c) Dressing includes assisting the individual with putting on, fastening, and taking off all items of clothing, braces, and artificial limbs, including obtaining and replacing items from their storage area in the immediate environment;

(d) Toileting includes assisting the individual in getting to and from, on and off, the toilet, commode, or bedpan for elimination of feces and urine. This includes cleansing after elimination and adjusting clothing as necessary or requested;

(e) Maintaining Continence includes reminders to use the toilet or commode, developing a continence schedule, assisting the individual with external cleansing of Foley catheter, emptying urinals, emptying bedside commode, emptying catheter drainage bag, maintenance bowel care, changing and replacing incontinence products, including colostomy or ileostomy bags;

(f) Transferring includes assisting the individual with mobility, transfers, ambulation, and repositioning by any means, including use of an assistive device and turning or adjusting padding for physical comfort or pressure relief and encouraging or assisting with range of motion exercises.

(9) IADLs capture more complex life activities and include personal hygiene, light housework, laundry, meal preparation, shopping, using electronic communication devices, medication management and money management:

(a) Personal hygiene includes performing or assisting the individual with activities required to keep one’s desired appearance, secure or fasten clothing, comb/brush hair, nail care, foot care, skin care, menstrual care, mouth care and oral hygiene, etc.;

(b) Light housework includes performing or assisting the individual with housekeeping tasks necessary to maintain the individual in a healthy and safe living environment;

(c) Laundry includes performing or assisting the individual with laundering or cleaning of clothing, bedding, and other linens;

(d) Meal preparation includes performing or assisting the individual with healthy meal planning and preparation, ensuring special diets are followed;

(e) Shopping includes performing or assisting the individual in planning for and purchasing of essential items including clothing, groceries, prescribed medication, hygiene products and basic household necessities;

(f) Using the telephone or other electronic communication devices includes performing or assisting the individual in arranging necessary appointments and making desired phone calls using a telephone, smart phone, tablet or other similar electronic device for communication purposes, including entering the phone number and connecting to secure telecommunication platforms;

(g) Medication assistance includes helping the individual with oral medications prescribed for the individual by a licensed medical professional, which are ordinarily self-administered described below:

(A) Organizing and preparing medication;

(B) Supervision or cueing to ensure the individual is taking medication as prescribed;

(D) Refilling prescriptions; and

(E) Assisting with use, maintenance, and cleaning of in-home medical equipment authorized by a licensed medical professional, including:

(i) Monitoring the individual’s condition;

(ii) Ordering and maintaining necessary supplies;

(iii) Use, maintenance, and cleaning of in-home medical equipment must be performed by PCA in compliance with manufacturers guidelines; and

(iv) PCA must have received prior training and education from an RN, when applicable, in how to correctly perform these tasks.

(h) Money Management includes performing or assisting the individual with budgeting, making payments for monthly expenses and use of personal funds for desired items and activities.

(10) Personal care services may be required due to cognitive impairments that prevent an individual from knowing when or how to carry out ADL/IADL tasks. In such cases, personal assistance may include cueing along with supervision to ensure the individual performs the task properly.

(11) Services outside the ADLs in section (8) and the IADLs in section (9) above are not eligible for payment. Payment may not be made by the Authority for any of the following excluded services:

(a) Shopping for entertainment purposes or non-essential items;

(b) Social companionship;

(d) Care, grooming, or feeding of pets or other animals except incidental assistance directly related to an assessed ADL or IADL need; or

(e) Yard work, gardening, or home repair.

(12) Delegated nursing tasks by a Registered Nurse (RN) under Oregon’s Nurse Practice Act may be considered personal care services when the RN provides appropriate training and delegation of the listed nursing tasks in accordance with the OAR chapter 851, division 047.

(13) Levels of assistance for determining IHPC service plan hours:

(a) "Minimal Assistance" means an individual can perform the majority of an activity but requires some assistance from another person. Even with assistive devices, the individual requires assistance of another person for a task at least once in a 30-day period. The assistance needed shall be related to ADL and IADL needs documented in the PCSP. This means hands-on assistance, cueing, or stand-by presence during the activity;

(b) "Substantial Assistance" means an individual can perform only a small portion of the tasks that comprise an activity without assistance from another person. The individual requires assistance with a task at least once in a 30-day period;

(c) "Full Assistance" means an individual needs assistance from another person through all tasks of an activity every time the activity is attempted. Even with assistive devices, the individual is unable to accomplish any tasks without the assistance of another person. This means the individual needs hands-on assistance of another person through all tasks of the activity, every time the activity is attempted.

(14) Maximum service period hours for ADL services:

(a) The person-centered planning process uses the following maximum hours limitations for each two-week service period for ADL tasks. Maximum hours in each assistance level are not guaranteed. Hours authorized must be based on the service needs of an individual as determined by the IQA during the person-centered service planning process;

(b) For in-home benefit plans the following maximums apply:

(A) Eating:

(i) Minimal assistance, up to three (3) hours;

(ii) Substantial assistance, up to nine (9) hours;

(iii) Full assistance, up to fourteen (14) hours;

(B) Dressing and grooming:

(i) Minimal assistance, up to two (2) hours;

(ii) Substantial assistance, up to seven (7) hours;

(iii) Full assistance, up to nine (9) hours;

(i) Minimal assistance, up to five (5) hours;

(ii) Substantial assistance, up to seven (7) hours;

(iii) Full assistance, up to twelve (12) hours;

(D) Mobility and transferring:

(i) Minimal assistance, up to five (5) hours;

(ii) Substantial assistance, up to seven (7) hours;

(iii) Full assistance, up to twelve (12) hours;

(E) Toileting and maintaining continence (bowel, and bladder):

(i) Minimal assistance, up to five (5) hours;

(ii) Substantial assistance, up to nine (9) hours;

(iii) Full assistance, up to fourteen (14) hours;

(F) Cognition:

(i) Minimal assistance, up to three (3) hours;

(ii) Substantial assistance, up to six (6) hours;

(iii) Full assistance, up to twelve (12) hours.

(c) PCSP hours for ADLs may only be authorized for an individual if the individual requires assistance (minimal, substantial, or full assist) from another person in the tasks associated with the activity of daily living as determined by a service assessment applying the parameters in this rule.

(d) The IQA may authorize fewer hours than the maximum number of hours in any or all ADL tasks based on their assessment of the individual’s unmet need.

(e) The IQA must document the reason for authorizing fewer hours than the maximum number of hours allowed. The IQA may authorize fewer hours than the maximum for any of the following reasons:

(A) Reduced frequency or duration of an ADL need;

(B) Durable medical equipment or home modification reduces need for assistance;

(D) Natural supports as defined in OAR 410-173-0005;

(E) Provided or funded by another agency.

(f) For households with two or more eligible individuals, each individual's ADL service needs must be considered separately.

(15) Maximum service period hours for IADL services:

(a) The person-centered planning process uses the following limitations for time allotments for IADL tasks. Maximum hours in each assistance level are not guaranteed. Hours authorized must be based on the unmet service needs of an individual as determined by the IQA during the person-centered service planning process:

(A) Medication management:

(i) Minimal assistance, up to one (1) hour;

(ii) Substantial assistance, up to two (2) hours;

(iii) Full assistance, up to five (5) hours;

(B) Personal Hygiene:

(i) Minimal assistance, up to five (5) hours;

(ii) Substantial assistance, up to seven (7) hours;

(iii) Full assistance, up to twelve (12) hours;

(i) Minimal assistance:

(I) Breakfast, up to one (1) hour;

(II) Lunch, up to one (1) hour;

(III) Supper, up to two (2) hours;

(ii) Substantial assistance:

(I) Breakfast, up to two (2) hours;

(II) Lunch, up to two (2) hours;

(III) Supper, up to three (3) hours;

(iii) Full assistance:

(I) Breakfast, up to five (5) hours;

(II) Lunch, up to five (5) hours;

(III) Supper, up to six (6) hours;

(D) Shopping:

(i) Minimal assistance, up to one (1) hour;

(ii) Substantial assistance, up to two (2) hours;

(iii) Full assistance, up to three (3) hours;

(E) Housekeeping and Laundry:

(i) Minimal assistance, up to two (2) hours;

(ii) Substantial assistance, up to five (5) hours;

(iii) Full assistance, up to nine (9) hours;

(F) Money Management:

(i) Minimal assistance, up to one (1) hours;

(ii) Substantial assistance, up to (two 2) hours;

(iii) Full assistance, up to three (3) hours;

(G) Use of Electronic Communication Devices or telephone:

(i) Minimal assistance, up to one (1) hours;

(ii) Substantial assistance, up to two (2) hours;

(iii) Full assistance, up to three (3) hours;

(b) Service plan hours for IADL tasks may only be authorized for an individual if the individual requires assistance (minimal, substantial, or full assist) from another person in that IADL task as determined by a service assessment applying the parameters in these rules. Hours authorized must incorporate the frequency and the duration of the tasks within each IADL. For housekeeping, the size of the home may be used to reduce the hours. For meal preparation, hours must be reduced if an individual is receiving Medicaid home delivered meals.

(c) The IQA may authorize fewer hours than the maximum number of hours in any or all IADLs based on their assessment of the individual's unmet need.

(d) The IQA must document the reason for authorizing fewer hours than the maximum hours. The IQA may reduce hours for any of the following reasons:

(A) Reduced frequency or duration of an IADL need;

(B) Durable medical equipment or home modification reduces need for assistance;

(D) Natural supports;

(E) Provided by or funded by another agency;

(F) Small living space.

(e) When two or more individuals eligible for IADL task hours live in the same household:

(A) Medication management and transportation shall be authorized separately for each eligible individual.

(B) For shared IADL tasks, payment is made for the individual with the highest of the allotments in meal preparation, shopping, and housekeeping and laundry and a total of two (2) additional IADL hours per service period for each additional individual to allow for the specific IADL needs of the additional individual’s specific IADL needs.

(16) When one or more eligible individuals are living in the same household and receiving in-home services, the total number of hours authorized for ADLs and IADLs may not exceed 24 hours within any 24-hour period in the same household unless an exception is granted as described in this rule.

(17) The Authority may approve an exception to the maximum service period hours when an individual's assessed needs cannot be adequately met within the standard assessed service limitations.

(a) The determination to authorize additional hours may be based on:

(A) An initial assessment or reassessment;

(B) Information identified through the person-centered service planning process; or

(C) Information provided by the individual or the individual's authorized representative and those who participated in the assessment and person- centered service planning process.

(b) Additional hours authorized under this section must be necessary to maintain the individual's health, safety, and welfare and be documented in the individual's PCSP.

(18) A PCA is limited to 16 hours of awake care during a 24-hour work period.

(19) All PCAs are limited to 60 hours per week unless the individual has received an exception described in (17).

(20) In an emergency or unanticipated situation where the PCA must provide critical care to ensure the health or safety of the individual and the IQA is unavailable to provide prior authorization, the following shall be permitted if the PCA or individual notifies the IQA within two (2) business days of the date the additional hours were first:

(a) Worked that exceed the hours authorized on the individual’s PCSP;

(b) Worked that exceed the maximum service period hours authorized by sections (14) and (15) of this rule; or

(c) Worked that exceed the awake care limitation in section (18) of this rule when the PCA must remain awake to provide necessary ADL care.

(21) A provider may not receive payment from the Authority for more than the total amount authorized by the Authority on the service plan authorization form. All service payments must receive prior authorization by the IQA. This section shall be waived unless the emergency provisions in section (20) of this rule are met.

(22) The IQA must assess and utilize as appropriate, natural supports, cost-effective assistive devices, durable medical equipment, housing accommodations, and alternative service resources as described in this rule that may reduce the need for paid assistance.

(23) The Authority may authorize paid in-home services only to the extent necessary to supplement potential or existing resources within an individual's natural supports system.

(24) Payment by the Authority for Medicaid IHPC services are only made for the tasks described in this rule as ADL or IADL tasks. Services must be authorized to meet the needs of an eligible individual and may not be provided to benefit an entire household.

History

Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025 & 414.065
DMAP 36-2026, temporary amend filed 08/20/2026, effective 08/20/2026 through 02/15/2027
DMAP 80-2025, adopt filed 10/28/2025, effective 10/28/2025

Or. Admin. R. 410-173-0110 Eligibility for HCBS-In-Home Personal Care

(1) To be eligible for IHPC services outlined in these rules, individuals shall:

(a) Be eligible for 1915(i) HCBS as outlined in these rules and OAR 410-173-0010;

(b) Have assessed needs for ADL’s and IADL’s as documented in the PCSP;

(c) Require assistance as documented and approved in the PCSP in two (2) areas of IADLs as outlined in these rules due to the symptoms of a behavioral health condition;

(d) Lack natural supports to consistently provide HCBS IHPC services;

(e) Access one or more 1915(i) services at least one time every 30 days.

(2) These services cannot duplicate services received through other authorities-Medicaid, Medicare, or other medical coverage.

(3) Individuals determined eligible to receive IHPC services shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided to meet the individual’s assessed needs. The individual’s choice shall be reflected by their signature, or, if appropriate, the legal or authorized representative’s signature indicating informed consent.

History

Statutory/Other Authority: ORS 413.042, 426.495, 430.610 & 430.630
Statutes/Other Implemented: ORS 413.042, 426.495, 430.610 & 430.630
DMAP 80-2025, adopt filed 10/28/2025, effective 10/28/2025

Division 174 Traditional Health Worker Culturally and Linguistically Specific Services

Or. Admin. R. 410-174-0000 Purpose and Scope

(1) These rules establish processes and procedures for traditional health workers and the programs and organizations they work for to receive enhanced payment for delivering culturally and linguistically specific physical health related services to patients on the Oregon Health Plan.

(2) These rules apply to organizations, programs and individuals that are reimbursed through OHP's fee schedule for physical health related services.

(3) These rules do not apply to organizations, programs and individuals that are reimbursed outside OHP’s fee schedule such as but not limited to Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), and Indian Health Care Providers (IHCPs), because such organizations, programs and individuals are already reimbursed at a clinic-specific encounter rate.

(4) All providers of health services are encouraged to provide culturally and linguistically specific services if they have that expertise whether or not a provider qualifies for enhanced payments through this program.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 48-2025, adopt filed 06/03/2025, effective 07/01/2025

Or. Admin. R. 410-174-0001 Definitions

(1) “Culturally and linguistically specific services” means quality health care or health care related services that are designed specifically for a distinct minoritized cultural community, developed based on the languages used and the cultural values of a distinct minoritized cultural community and designed to elevate their voices and experiences, and that aim to enhance emotional safety, belonging and a shared collective cultural experience for healing and promotion of health among the distinct cultural community.

(2) “Culturally and linguistically specific services organization” means an organization providing outpatient care or a community-based organization, group or association providing culturally and linguistically specific health care or health related services, or both, in its entirety as evidenced by its organizational mission.

(3) “Culturally and linguistically specific services program” means a division or associated component of an organization that provides culturally and linguistically specific health care or health related services, or both, as evidenced by the program’s mission, that exists within the subset of services provided by an organization whose mission may, but is not required to, focus on a distinct minoritized cultural community.

(4) “Culturally and linguistically specific traditional health worker provider” means a traditional health worker enrolled with OHA as an Oregon Health Plan (OHP) provider and deemed eligible by OHA to receive enhanced payments for culturally and linguistically specific services.

(5) “Minoritized cultural community” is a community that has experienced historical and contemporary discrimination and oppression primarily on the basis of race, ethnicity, gender identity, sexual and affectional orientation, ability status, and/or migration history.

(6) “OHA” means the Oregon Health Authority.

(7) “Provider” is an individual, or entity enrolled with OHA’s Medicaid program and authorized to bill for Medicaid eligible services.

(8) “These rules” means OAR 410-174-0000 to 410-174-0040

(9) “Traditional health worker” means ORS 414.665 and OAR 950, Division 60.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 48-2025, adopt filed 06/03/2025, effective 07/01/2025

Or. Admin. R. 410-174-0010 Culturally and Linguistically Specific Services Organization

(1) In order to qualify for enhanced payments for culturally and linguistically specific services provided by traditional health workers as an organization, the organization must:

(a) Be enrolled as a provider and reimbursed through OHP’s fee schedule for physical health services;

(b) Submit a complete Traditional Health Worker Culturally and Linguistically Specific Services application to OHA;

(d) Have traditional health workers working with or being immersed in the same distinct minoritized community being served; or

(e) Have a history of at least one year experience primarily serving the specified minoritized cultural community being served.

(2) To demonstrate the ability to serve a minoritized cultural community under section (1)(c) of this rule an organization must provide information that shows the following:

(a) Comprehensive knowledge of diverse lived experiences held by the minoritized cultural community being served including, but not limited to, their experiences of structural and individual racism, minoritization or discrimination that may have an impact on the community’s collective health and wellbeing.

(b) Knowledge of specific health inequities documented in the minoritized cultural community being served, which may be addressed by the organization.

(c) A practice of supporting and affirming cultural and language practices for the community being served, such as but not limited to:

(A) Health and safety beliefs, or practices;

(B) Positive cultural identity, pride, or resilience;

(D) Sacred beliefs.

(d) A demonstrated ability to support and affirm clients experiencing intersectional oppression in the provision of services. The ability to support and affirm the unique needs of clients experiencing intersectional oppression may be evidenced through details of the organization’s established collaboration with other culturally specific providers, details of dedicated spaces or groups provided for clients experiencing intersectional oppression, or any other supporting information.

(3) The information required to be provided under section (1)(b) through (e) and (2) of this rule must include documentation of the organization’s culturally specific focus demonstrated in a mission statement, vision statement, or other public-facing document. Supporting information can also include but is not limited to:

(a) Documentation detailing policies and procedures.

(b) Documentation of staff training requirements and any resulting certifications.

(c) A narrative that details the organization or program’s strategic plan or history and experience, including specific examples, without identifying any individual clients.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 48-2025, adopt filed 06/03/2025, effective 07/01/2025

Or. Admin. R. 410-174-0020 Culturally and Linguistically Specific Services Program Qualifications

(1) In order to qualify for enhanced payments for culturally and linguistically specific services provided by traditional health workers as a program, the program must:

(a) Be enrolled as a provider and reimbursed through OHP’s fee schedule for physical health services;

(b) Submit a complete Culturally and Linguistically Specific Services Traditional Health Worker application to OHA.

(d) Have traditional health worker staff working with or being immersed in the same minoritized community being served; or

(e) Ensure traditional health worker staff have a history of at least one year experience primarily serving the specified cultural community being served.

(2) To demonstrate the ability to serve a minoritized cultural community under (1) (c) of this rule, a program must provide information that shows the following:

(b) Knowledge of specific health inequities documented in the minoritized cultural community being served, which may be addressed by the program.

(c) A practice of supporting and affirming cultural and language practices of the minoritized cultural community being served, such as but not limited to:

(A) Health and safety beliefs, or practices;

(B) Positive cultural identity, pride, or resilience;

(D) Sacred beliefs.

(d) A demonstrated ability to support and affirm clients experiencing intersectional disparities in the provision of services. The ability to support and affirm the unique needs of clients experiencing intersectional oppression may be evidenced through details of the program’s established collaboration with other culturally specific providers, details of dedicated spaces or groups provided for clients experiencing intersectional oppression, or any other supporting information.

(3) The information required to be provided under section (1)(b) through (e) and (2) of this rule must include documentation of the program’s culturally specific focus demonstrated in a mission statement, vision statement, or other public-facing document. Supporting information can also include but is not limited to:

(a) Documentation detailing policies and procedures.

(b) Documentation of staff training requirements and any resulting certifications.

(c) A narrative that details the program’s strategic plan or history and experience, including specific examples, without identifying any individual clients.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 48-2025, adopt filed 06/03/2025, effective 07/01/2025

Or. Admin. R. 410-174-0030 Culturally and Linguistically Specific Services Individual Traditional Health Worker Qualifications

(1) In order to qualify for enhanced payments for culturally and linguistically specific traditional health worker services, an individual must:

(a) Be enrolled as a provider and reimbursed through OHP’s fee schedule for physical health services.

(b) Be a Traditional Health Worker.

(d) Demonstrate the ability to serve a minoritized cultural community.

(2) To demonstrate the ability to serve a particular minoritized community under (1) (c) of this rule, an individual must provide information that shows the following:

(b) Knowledge of specific social/physical health inequities documented in the minoritized cultural community being served, which may be addressed by the culturally and linguistically specific services of the individual;

(c) A practice of supporting and affirming cultural and language practices for the minoritized cultural community being served, such as but not limited to:

(A) Health and safety beliefs or practices;

(B) Positive cultural identity, pride, or resilience;

(D) Sacred beliefs.

(d) A demonstrated ability to support and affirm clients experiencing intersectional oppression in the provision of services. The ability to support and affirm the unique needs of clients experiencing intersectional oppression may be evidenced through details of the individual’s established collaboration with other culturally specific providers, details of dedicated spaces or groups provided for clients experiencing intersectional oppression, or any other supporting information; and

(e) Have extensive experience working with or being immersed in the same minoritized cultural community being served; or

(f) Have a history of at least one year of experience primarily serving a specified minoritized cultural community.

(3) The information required to be provided under section (1)(b) and (c) and (2) of this rule can include, but is not limited to:

(a) A resume or curriculum vitae detailing academic credentials, relevant course work, work history, or certifications; or

(b) A narrative that details the individual’s professional history and experience, including specific examples, without identifying clients.

History

Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
DMAP 48-2025, adopt filed 06/03/2025, effective 07/01/2025

Division 200 ELIGIBILITY FOR HEALTH SYSTEMS DIVISION MEDICAL PROGRAMS

Or. Admin. R. 410-200-0010 Overview.

These rules, OAR 410-200-0010 through 410-200-0510, describe eligibility requirements for the Health Systems Division (HSD) Medical Programs.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0015 General Definitions

(1) “Action” means a termination, suspension, denial, or reduction of Medicaid or CHIP eligibility or covered services.

(2) “Active renewal” means the renewal process for cases that are not processed via automated renewal wherein a prepopulated renewal notice is sent to the head of household and authorized representative, if applicable. The active renewal notice is populated with the most current case information relevant to renewal.

(3) “Address Confidentiality Program (ACP)” means a program of the Oregon Department of Justice that provides a substitute mailing address and mail forwarding service for ACP participants who are victims of domestic violence, sexual assault, or stalking.

(4) Assumed Eligible Newborn (AEN) means (OAR 410-200-0115).

(5) “Affordable Care Act” means the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111–148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111–152), as amended by the Three Percent Withholding Repeal and Job Creation Act of 2011 (Pub. L. 112–56).

(6) “Agency” means the Oregon Health Authority and Oregon Department of Human Services.

(7) “Applicant” means an individual who is seeking an eligibility determination for themselves or someone for whom they are applying through an application submission or a transfer from another agency, insurance affordability program, or the FFM.

(8) “Application” means:

(a) The single streamlined application for all insurance affordability programs developed by the Authority or the FFM; or

(b) An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard, submitted by or on behalf of the individual who may be eligible or is applying for assistance on a basis other than the applicable MAGI standard.

(9) Advance payments of the premium tax credit (APTC), means payment of the tax credits specified in section 36B of the Internal Revenue Code (as added by section 1401 of the Affordable Care Act) that are provided on an advance basis to an eligible individual enrolled in a QHP through an Exchange in accordance with sections 1402 and 1412 of the Affordable Care Act.

(10) “Assumed eligibility” means an individual is deemed to be eligible for a period of time based on receipt of another program benefit or because of another individual’s eligibility.

(11) “Authorized Representative” means an individual at least 18 years of age or organization that acts on behalf of an applicant or beneficiary in assisting with the individual’s application and renewal of eligibility and other on-going communications with the Agency (OAR 410-200-0111).

(12) “Automated renewal” means a renewal of eligibility, initiated by the Agency, based on reliable information contained in the beneficiary’s case record, using the Federal Data Services Hub and automated electronic verification sources available to the agency to perform data matches for the sake of verifying eligibility criteria.

(13) “Beneficiary” means an individual who has been determined eligible and is currently receiving HSD Medical Program benefits, Aging and People with Disabilities medical program benefits, or APTC.

(14) Behavior Rehabilitation Services (BRS) means a program that provides services and placement-related activities to the BRS client to address their debilitating psychosocial, emotional, and behavioral disorders in a community placement utilizing either a residential care model or a proctor care model (OAR 410-170-0020).

(15) “Budget month” means the calendar month from which financial and nonfinancial information is used to determine eligibility.

(16) “Caretaker” means a parent, caretaker relative, or non-related caretaker who assumes primary responsibility for a child’s care.

(17) “Caretaker relative” means an individual with whom the child is living who assumes primary responsibility for the child’s care, and who is one of the following:

(a) A relative of the dependent child, as follows:

(A) A biological relative, including parents, siblings, first cousins, nephews, nieces, and individuals of preceding generations as denoted by prefixes of grand, great, or great-great.

(B) Step-parent and step-siblings.

(b) The spouse of the parent or relative even after the marriage is terminated by death or divorce.

(18) Citizenship Waived Medical (CWM) was a benefit package that ended on June 30, 2023. The CWM benefit package covered certain emergency services provided to individuals who met the financial and non-financial eligibility requirements for an HSD Medical Program, except they did not meet citizenship and non-citizen status requirements (OAR 410-200-0215). For information about CWM benefits and eligibility prior to July 1, 2023, see OARs 410-134-0005 and 410-200-0240.

(19) Citizenship Waived Medical Plus (CMW Plus) was a benefit package that was previously referred to as “CWX” and ended on June 30, 2023. CWM Plus provided OHP Plus benefits to pregnant individuals and individuals who were sixty (60) days post-partum and who met the financial and non-financial status requirements for an HSD Medical Program, except they did not meet the citizenship and non-citizen status requirements identified in OAR 410-200-0215. For more information about CWM Plus benefits and eligibility prior to July 1, 2023, see OARs 410-134-0005 and 410-200-0240.

(20) “Child” means an individual including minor parent, under the age of 19. Child does not include an unborn.

(21) Children’s Health Insurance Program (CHIP) means Oregon medical coverage under Title XXI of the Social Security Act.

(22) “Citizenship” includes status as a “national of the United States” defined in 8 U.S.C. 1101(a) (22) that includes both citizens of the United States and non-citizen nationals of the United States.

(23) “Claim” means a legal action or a demand by, or on behalf of, an applicant or beneficiary for damages for or arising out of a personal injury that is against any person, public body, agency, or commission other than the State Accident Insurance Fund Corporation or Worker’s Compensation Board.

(24) “Claimant” means an individual who has requested a hearing or appeal.

(25) “Code” means Internal Revenue Code.

(26) “Combined Eligibility Notice” means an eligibility notice that informs an individual, or multiple family members of a household when feasible, of eligibility for each of the HSD Medical Programs for which a determination or denial was made by the Authority.

(27) “Community Partner” has the same meaning as “Community Partner” as defined in OAR 410-120-0000.

(28) “Coordinated content” means information included in an eligibility notice regarding the transfer of the individual’s or household’s electronic account to another insurance affordability program for a determination of eligibility.

(29) “Cover All Kids” refers to the OHP Plus-equivalent benefit (OAR 410-120-1210) provided to children who meet all eligibility requirements for MAGI Medicaid/CHIP except for the Citizenship and Non-Citizen Status Requirements (OAR 410-200-0215). As of July 1, 2022, Cover All Kids is included under Healthier Oregon as defined in OAR 410-134-0001.

(30) “Custodial Parent” means, for children whose parents are divorced, separated, or unmarried, the parent with whom the child lives, with the following considerations:

(a) If the child lives part-time with both parents, the parent with whom the child spends most nights is the custodial parent; or

(b) If section (30) subsection (a) cannot be determined due to the child spending equal nights with both parents, a court order or binding custody agreement establishing physical custody is used to identify the custodial parent.

(31) “Date of Request (DOR)” means the date on which the applicant or an individual authorized to act on behalf of the applicant contacts the Authority, the Department, or the FFM to request medical benefits.

(a) For new applicants, the DOR is established as follows:

(A) The date the request for medical benefits is received by the Agency, the FFM, or a community partner; or

(B) The date the applicant received a medical service, if the request for medical benefits is received by midnight of the following business day.

(b) For current beneficiaries of HSD Medical Programs, the Date of Request is:

(A) The date the beneficiary or someone authorized to act on the beneficiary’s behalf reports a change requiring a redetermination of eligibility;

(B) The month an individual ages off a medical program.

(C) For Automated Renewals the Date of Request is the date the Agency initiates the Automated Renewal if there is no RFI generated; or

(D) For Active Renewals, and for Automated Renewals which result in the generation of an RFI, the Date of Request is the date on which the Agency receives a response to the Active renewal or RFI.

(c) The request may be submitted via the Internet, by telephone, community partner, by mail, by electronic communication, or in person.

(32) “Decision notice” means a written notice of a decision made regarding eligibility for an HSD Medical Program benefit. The following are types of decision notices:

(a) “Basic decision notice” which is mailed no later than the date of action given in the notice;

(b) “Combined decision notice” which informs an individual or multiple family members of a household of the eligibility decision made for each of the medical assistance programs;

(c) “Timely continuing benefit decision notice” which informs the client of the right to continued benefits and is mailed no later than ten (10) calendar days before the effective date of the change, except for clients in the Address Confidentiality Program, for whom it shall be mailed no later than fifteen (15) calendar days before the effective date of the change.

(33) “Department” means the Oregon Department of Human Services.

(34) “Dependent child” means an individual who:

(a) Is under the age of 18 or age 18 and a full-time student in a secondary school or equivalent vocational or technical training, if the individual may reasonably be expected to complete the school or training before attaining age 19.

(b) Lives in the home of the caretaker relative; and

(c) Is not absent from the home for more than thirty (30) days due to being in foster care while foster care payments are being made.

(35) “Express Lane Agency (ELA)” means the Oregon Department of Human Services making determinations regarding one or more eligibility requirements for the MAGI Child or MAGI CHIP programs.

(36) “Express Lane Eligibility (ELE)” means the Oregon Health Authority’s option to rely on a determination made within a reasonable period by an ELA finding that a child satisfies the requirements for MAGI Child or MAGI CHIP program eligibility.

(37) “Electronic account” means an electronic file that includes all information collected and generated by the Agency regarding each individual’s Medicaid or CHIP eligibility and enrollment, including all documentation and information collected or generated as part of a fair hearing process conducted by the Authority or the FFM appeals process.

(38) “Electronic application” means an application electronically signed and submitted through the Internet.

(39) “Eligibility determination” means an approval, denial, renewal, or termination of eligibility.

(40) “Eligibility Determination Group” (EDG) means all persons whose financial and non-financial information is considered in determining each medical applicant’s eligibility as defined in OAR 410-200-0305.

(41) “Expedited appeal” also called “expedited hearing” means a hearing held within five (5) working days of the Agency’s receipt of a hearing request, unless the claimant requests more time.

(42) “Family Size” means the number of individuals used to compare to the income standards chart for the applicable program. The family size consists of all members of the EDG and each unborn child of any pregnant members of the EDG.

(43) “Federal Data Services Hub” means an electronic service established by the Secretary of the Department of Health and Human Services through which all insurance affordability programs can access specified data from pertinent federal agencies needed to verify eligibility, including the Social Security Administration composite, the Department of Treasury, and the Department of Homeland Security.

(44) “Federal Poverty Level (FPL)” means the federal poverty level updated periodically in the Federal Register by the Secretary of the Department of Health and Human Services under the authority of 42 U.S.C. 9902(2) as in effect for the applicable budget period used to determine an individual’s eligibility in accordance with 42 CFR 435.603(h).

(45) “Federally Facilitated Marketplace (FFM)” means the online marketplace operated by the US Department of Health and Human Services which determines eligibility for Advanced Premium Tax Credit (APTC) and Cost Sharing Reductions (CSR). The FFM also performs eligibility assessments for Oregon Medicaid/CHIP and refers to the Agency electronic accounts of individuals who are found potentially eligible.

(46) “Head of household (HOH)” means the primary person the Agency shall communicate with and:

(a) Is listed as the case name; or

(b) Is the individual named as the primary contact on the application.

(47) “Health Systems Division Medical Programs (HSD Medical Programs)" means all programs under the Health Systems Division, except when the eligibility decision is made through a Hospital Presumptive Eligibility determination (OAR 410-200-0105), including:

(a) Extended Medical Assistance (EXT);

(b) Substitute Care;

(d) Former Foster Care Youth Medical (FFCYM);

(e) OHP Bridge - Basic Health Program

(f) “MAGI Medicaid/CHIP” means HSD Medical Programs for which eligibility is based on MAGI methodology, including:

(A) MAGI Child;

(B) MAGI Parent or Caretaker Relative;

(D) MAGI Children’s Health Insurance Program (CHIP);

(E) MAGI Adult;

(F) OHP Bridge -Basic Medicaid; and

(G) Young Adults with Special Health Care Needs (YSHCN).

(48) “Healthier Oregon” is defined in OAR 410-120-0000(131).

(49) “Hearing request” means a clear expression, oral or written, by an individual or the individual’s representative that the individual wishes to appeal an Authority or FFM decision or action.

(50) “Insurance affordability program” means one of the following programs:

(a) Medicaid;

(b) CHIP;

(c) A program that makes coverage available in a qualified health plan through the FFM with advance payments of the premium tax credit established under section 36B of the Internal Revenue Code available to qualified individuals;

(d) A program that makes coverage available in a qualified health plan through the FFM with cost-sharing reductions established under section 1402 of the Affordable Care Act.

(51) “Legal argument” has the meaning given in OAR 137-003-0008(c).

(52) “Medicaid” means Oregon’s Medicaid program under Title XIX of the Social Security Act.

(53) Modified Adjusted Gross Income (MAGI) has the meaning defined in OAR 410-200-0310(4) and is used in determining eligibility based on annual income. MAGI has the meaning provided at IRC 36B(d)(2)(B) and generally means federally taxable income with the following exceptions:

(a) The income of the following individuals is excluded when they are not expected to be required to file a tax return for the tax year in which eligibility is being determined. This subsection applies whether or not the child or tax dependent actually files a tax return:

(A) Children, regardless of age, who are included in the household of a parent;

(B) Tax dependents.

(b) In applying section (53)(a), IRC § 6012(a) (1) is used to determine who is required to file a tax return.

(54) “MAGI-based income” means income calculated using the same financial methodologies used to determine MAGI as defined in section 36B(d)(2)(B) of the Code with the following exceptions:

(a) An amount received as a non-recurring lump sum, if taxable, is counted as income only in the month received;

(b) Scholarships, awards, or fellowship grants used for education purposes and not for living expenses are excluded;

(A) Distributions from Alaska Native Corporations and Settlement Trusts;

(B) Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation or otherwise under the supervision of the Secretary of the Interior;

(C) Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest, including farming, from:

(i) Rights of ownership or possession in any lands described in subsection (c)(B) of this section; or

(ii) Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources.

(D) Distributions resulting from real property ownership interests related to natural resources and improvements:

(i) Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or

(ii) Resulting from the exercise of federally protected rights relating to such real property ownership interests.

(E) Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom;

(F) Student financial assistance provided under the Bureau of Indian Affairs education programs.

(55) “Minimum Essential Coverage (MEC)” means medical coverage under:

(a) A government-sponsored plan, including Medicare Part A, Medicaid (excluding CWM), CHIP, TRICARE, the veterans’ health care program, and the Peace Corps program;

(b) Employer-sponsored plans with respect to an employee, including coverage offered by an employer that is a government plan, any other plan or coverage offered in the small or large group market within the state, and any plan established by an Indian tribal government;

(d) Health insurance plans in place on or before March 23, 2010; and

(e) Any other health benefits coverage, such as a state health benefits risk pool, as recognized by the HHS secretary in coordination with the Treasury Secretary.

(56) “Non-applicant” means an individual not seeking an eligibility determination for themselves and is included in an applicant’s or beneficiary’s household to determine eligibility for the applicant or beneficiary.

(57) “Non-citizen” means any individual who is not a citizen or national of the United States as defined at 8 U.S.C. 1101(a)(22).

(58) Oregon Supplemental Income Program Medical (OSIPM) means medical coverage for individuals who are 65 years of age or older, who are blind, or who have a disability. This program is administered by the Oregon Department of Human Services.

(59) “Parent” means a natural or biological, adopted, or stepparent.

(60) “Personal Injury” means a physical or emotional injury to an individual including, but not limited to, assault, battery, or medical malpractice arising from the physical or emotional injury.

(61) “Primary Contact” has the same meaning given “head of household” in this rule.

(62) “Psychiatric Residential Treatment Facility (PRTF) means a facility that is a structured residential treatment environment with daily 24-hour supervision and active psychiatric treatment including Psychiatric Residential Treatment Services (PRTS), Secure Children’s Inpatient Treatment Programs (SCIP), Secure Adolescent Inpatient Treatment Programs (SAIP), and Sub-acute Psychiatric Treatment for children who require active treatment for a diagnosed mental health condition in a 24-hour residential setting.

(63) “Public institution” means any of the following:

(a) A state hospital (ORS 162.135);

(b) A local correctional facility (ORS 169.005), a jail, or prison for the reception and confinement of prisoners that is provided, maintained, and operated by a county or city and holds individuals for more than 36 hours;

(c) A Department of Corrections institution (ORS 421.005), a facility used for the incarceration of individuals sentenced to the custody of the Department of Corrections, including a satellite, camp, or branch of a facility;

(d) A youth correction facility (ORS 162.135):

(A) A facility used for the confinement of youth offenders and other individuals placed in the legal or physical custody of the youth authority, including a secure regional youth facility, a regional accountability camp, a residential academy and satellite, and camps and branches of those facilities; or

(B) A facility established under ORS 419A.010 to 419A.020 and 419A.050 to 419A.063 for the detention of children, wards, youth or youth offenders pursuant to a judicial commitment or order.

(e) As used in this rule, the term public institution does not include:

(A) A medical institution as defined in 42 CFR 435.1010 including the Secure Adolescent Inpatient Program (SAIP) and the Secure Children's Inpatient Program (SCIP);

(B) An intermediate care facility as defined in 42 CFR 440.140 and 440.150; or

(C) A publicly operated community residence that serves no more than sixteen (16) residents, as defined in 42 CFR 435.1009.

(64) “Qualified hospital” means a hospital that meets all of the following criteria:

(a) Participates as an enrolled Oregon Medicaid provider;

(b) Notifies the Authority of their decision to make presumptive eligibility determinations;

(d) Informs applicants for presumptive eligibility of their responsibility to complete a full application by the end of the presumptive eligibility period and offers applicants assistance with completing and submitting the full Medicaid application; and

(e) Are not disqualified by the Authority for violations related to standards established for the presumptive eligibility program under 42 CFR § 435.1110(d).

(65) “Reasonable opportunity period”;

(a) May be used to obtain necessary verification or resolve discrepancies regarding an attestation of US citizenship or non-citizen status (OAR 410-200-0230 (2));

(b) Begins on and shall extend ninety (90) days from the date on which notice is received by the individual. The date on which the notice is received is considered to be five (5) days after the date on the notice, unless the individual shows they did not receive the notice within the five (5) day period;

(c) May be extended beyond ninety (90) days for individuals declaring a non-citizen status, if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation or the Agency needs more time to complete the verification process.

(66) “Redetermination” means a review of eligibility outside of regularly scheduled renewal. Redeterminations that result in the assignment of a new renewal date are considered renewals.

(67) “Renewal” means a regularly scheduled periodic review of eligibility.

(68) “Request for information (RFI)” means a notice sent by the agency to request additional information or verification of information. An RFI may be sent when attested information is not reasonably compatible with information obtained through an electronic data match, or when information or verification is needed that is not available through an electronic data match.

(69) “Resident of a Public Institution” means;

(a) An individual residing in a public institution that is:

(A) Confined involuntarily in a local, state, or federal prison, jail, detention facility, or other penal facility, including being held involuntarily in a detention center awaiting trial or serving a sentence for a criminal offense;

(B) Residing involuntarily in a facility under a contract between the facility and a public institution where, under the terms of the contract, the facility is a public institution;

(D) Receiving care as an outpatient while residing involuntarily in a public institution.

(b) An individual is not considered a resident of a public institution when the individual is:

(A) Released on parole, probation, or post-prison supervision;

(B) On home- or work-release, unless the individual is required to report to a public institution for an overnight stay;

(C) Receiving inpatient care at a medical institution not associated with the public institution where the individual is a resident. An individual is an inpatient when they’ve been admitted to a medical institution on the recommendation of a physician:

(i) Expects to receive room, board, and professional services in the medical institution for a 24-hour period or longer; or

(ii) Is expected to meet the criteria outlined in subsection (i) of this rule, but later dies, is discharged, or is transferred to another medical or extended care facility and does not actually stay in the medical institution for 24 hours.

(D) Residing voluntarily in a detention center, jail, or county penal facility after their case has been adjudicated and while other living arrangements are being made for the individual.

(E) Residing in a public institution pending other arrangements as defined in 42 CFR 435.1010; or

(F) Residing in an Institution for Mental Disease (IMD), including the Oregon State Hospital and:

(i) Is under age 21;

(ii) Is age 21 but was admitted to the IMD before their 21st birthday; or

(iii) Is age 65 or older.

(70) “Secure electronic interface” means an interface which allows for the exchange of data between Medicaid or CHIP and other insurance affordability programs and adheres to the requirements in 42 CFR part 433, subpart C.

(71) “Shared eligibility service” means a common or shared eligibility system or service used by a state to determine individuals’ eligibility for insurance affordability programs.

(72) “Sibling” means natural or biological, adopted, half or step sibling.

(73) “Spouse” means an individual who is legally married to another individual under:

(a) The statutes of the state where the marriage occurred;

(b) The common law of the state in which two individuals previously resided while meeting the requirements for common law marriage in that state; or

(c) The laws of a country in which two individuals previously resided while meeting the requirements for legal marriage in that country.

(74) “SSA” means Social Security Administration.

(75) “Tax dependent” has the meaning given the term “dependent” under section 152 of the Internal Revenue Code, as an individual for whom another individual claims a deduction for a personal exemption under section 151 of the Internal Revenue Code for a taxable year.

(76) “Title IV-E” means Title IV-E of the Social Security Act (42 U.S.C. §§ 671-679b).

(77) “Young Adults with Special Health Care Needs” or “YSHCN” means a program for young adults who meet pre-determined social and clinical criteria, which provides supplementary benefits, in addition to OHP Plus coverage, including EPSDT, HRSN services, and extended vision and dental services.

History

Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038, 414.025 & 414.534
Statutes/Other Implemented: ORS 411.095, 411.402, 411.404, 413.038, 414.025, 414.534, 411.400, 411.406, 411.439, 413.032, 414.231, 414.536, 414.706 & 414.241
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 12-2023, amend filed 03/30/2023, effective 04/01/2023
DMAP 84-2022, amend filed 11/29/2022, effective 11/29/2022
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 33-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 86-2018, amend filed 08/23/2018, effective 09/11/2018
DMAP 24-2018, temporary amend filed 04/27/2018, effective 04/29/2018 through 10/25/2018
DMAP 23-2018, amend filed 04/27/2018, effective 04/29/2018
DMAP 44-2017, temporary amend filed 11/01/2017, effective 11/01/2017 through 04/29/2018
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0100 Coordinated Eligibility and Enrollment Process with the Department of Human Services and the Federally Facilitated Marketplace

(1) This rule describes the coordination of eligibility and enrollment between the Oregon Health Authority (Authority), the Oregon Department of Human Services (Department), and the FFM. The Agency shall:

(a) Minimize the burden on individuals seeking to obtain or renew eligibility or to appeal a determination of eligibility for insurance affordability programs;

(b) Ensure determinations of eligibility and enrollment in the appropriate program without undue delay, consistent with timeliness standards described in OAR 410-200-0110 based on the application date;

(d) Screen every applicant or beneficiary who submits an application, renewal, or reports a change requiring redetermination of eligibility for criteria that identify individuals for whom MAGI and MAGI-based income methods do not apply.

(2) For individuals undergoing eligibility determinations for HSD Medical Programs, the Agency, consistent with the timeliness standards described in OAR 410-200-0110, shall:

(a) Determine eligibility for MAGI Medicaid/CHIP on the basis of having household income at or below the applicable MAGI-based standard; or

(b) If ineligible under section (2)(a), direct those individuals as appropriate to the FFM.

(3) The Agency shall, consistent with the timeliness standards described in OAR 410-200-0110, Screen for eligibility for non-MAGI programs as indicated by information provided on the application or renewal form.

(4) For HSD Medical Program beneficiaries who become ineligible for ongoing HSD Medical Program benefits, if an evaluation for non-MAGI programs is indicated by information provided in the case record, the Agency shall maintain HSD Medical Program benefits while eligibility for non-MAGI programs is being determined, and shall not take action to close benefits until determination of eligibility is complete.

(5) Coordination among agencies:

(a) The Agency shall maintain a secure electronic interface through which the Authority can send and receive an individual’s electronic account from the FFM;

(b) The Agency may not request information or documentation from the individual included in the individual’s electronic account or provided for the sake of other Agency benefits; and

(c) If information is available through electronic data match and is useful and related to eligibility for HSD Medical Programs, the Agency shall obtain the information through electronic data match.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 411.447, 414.534, 414.536 & 414.706
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 32-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0105 Hospital Presumptive Eligibility

With the exception of OHP Bridge - Basic Medicaid and YSHCN, this rule sets out when an individual is presumptively eligible for MAGI Medicaid/CHIP, BCCTP, and FFCYM (OAR 410-200-0407) based on the determination of a qualified hospital. In addition, presumptive eligibility for OHP Bridge Basic Health Program cannot be established based on the determination of a qualified hospital.

(1) A qualified hospital shall, with the consent of the individual or someone acting on the individual’s behalf, determine Hospital Presumptive Eligibility (HPE) for MAGI Medicaid/CHIP, BCCTP, or FFCYM.

(2) The qualified hospital shall determine Hospital Presumptive Eligibility based on the following information attested by the individual:

(a) Family size;

(b) Household income;

(d) Residency

(e) US citizenship, US national, or non-citizen status.

(3) To be eligible via Hospital Presumptive Eligibility, an individual must be a US citizen, US National, or meet the citizenship and non-citizen status requirements found in OAR 410-200-0215 and one of the following:

(a) A child under the age of 19 with income at or below 300 percent of the federal poverty level;

(b) A parent or caretaker relative of a dependent child with income at or below the MAGI Parent or Caretaker Relative income standard for the appropriate family size in OAR 410-200-0315;

(d) A non-pregnant adult between the ages of 19 through 64 with income at or below 133 percent of the federal poverty level; or

(e) An individual under the age of 65 who has been screened by a licensed healthcare provider and determined to need treatment for breast or cervical cancer, or who has been determined eligible for the Breast and Cervical Cancer Treatment Program (OAR 410-200-0400);

(f) An individual under the age of 26 who was in Oregon foster care on their 18th birthday.

(4) To be eligible via Hospital Presumptive Eligibility, an individual may not:

(a) Be receiving Supplemental Security Income benefits;

(b) Be a Medicaid/CHIP beneficiary; or

(c) Have received a Hospital Presumptive Eligibility approval start date within the year (365 days) prior to a new Hospital Presumptive Eligibility period start date.

(5) In addition to the requirements outlined in sections (3) and (4) above, the following requirements also apply:

(a) To receive MAGI Adult benefits via Hospital Presumptive Eligibility, an individual may not be entitled to or enrolled in Medicare benefits under part A or B of Title XVIII of the Act;

(b) To receive MAGI CHIP benefits via Hospital Presumptive Eligibility, an individual may not be covered by any minimum essential coverage that is accessible (OAR 410-200-0410(2)(c));

(c) To receive BCCTP benefits via Hospital Presumptive Eligibility, an individual may not be covered by any minimum essential coverage.

(6) The Hospital Presumptive Eligibility period begins on the earlier of:

(a) The date the qualified hospital determines the individual is eligible; or

(b) The date that the individual received a covered medical service from the qualified hospital, if the hospital determines the individual is eligible and submits the decision to the Authority within five (5) calendar days following the date of service.

(7) The Hospital Presumptive Eligibility period ends:

(a) For individuals on whose behalf a Medicaid/CHIP application has been filed by the last day of the month following the month in which the hospital presumptive eligibility period begins, the day on which the state makes an eligibility determination for MAGI Medicaid/CHIP and sends basic decision notice; or

(b) If subsection (7)(a) is not completed, the last day of the month following the month in which the hospital presumptive eligibility period begins.

(8) A Hospital Presumptive Eligibility approval is not a full eligibility determination and does not entitle beneficiaries to the following:

(a) A child is not entitled to continuous eligibility (OAR 410-200-0135) based solely on the receipt of benefits during a period of Hospital Presumptive Eligibility;

(b) A baby born to an individual receiving benefits during a period of hospital presumptive eligibility is not assumed eligible (OAR 410-200-0135) based solely the Hospital Presumptive Eligibility determination of the parent;

(c) An individual is not entitled to EXT (OAR 410-200-0440) based solely on the receipt of MAGI PCR during a period of Hospital Presumptive Eligibility;

(d) An individual is not entitled to receive YSHCN benefits as described in OAR 410-200-0455;

(e) An individual whose Hospital Presumptive Eligibility period is terminated due to incarceration is not entitled to automatic restoration of benefits upon release (OAR 410-200-0140);

(f) Individuals are not entitled to hearing rights (OAR 410-200-0145) for benefits received during a period of Hospital Presumptive Eligibility.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536, 414.706 & 414.241
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0110 Application and Renewal Processing and Timeliness Standards

(1) General information as it relates to application processing is as follows:

(a) An individual may apply for one or more medical programs administered by the Authority, the Department, or the Federally Facilitated Marketplace (FFM) using a single streamlined application;

(b) An application may be submitted via the Internet, the FFM, by telephone, by mail, in person, or through other commonly available electronic means;

(c) The Agency shall ensure that an application form is readily available to anyone requesting one and that community partners or Agency staff are available to assist applicants to complete the application process;

(d) If the Agency requires additional information to determine eligibility, the Agency shall send the applicant or beneficiary a request for information (RFI) which includes a statement of the specific information needed to determine eligibility and the date by which the applicant or beneficiary shall provide the required information in accordance with section (6) of this rule.

(e) If an application is filed containing the applicant or beneficiary’s name and address, the Agency shall send the applicant or beneficiary a decision notice within the time frame established in section (6) of this rule;

(f) An application is complete if all the following requirements are met:

(A) All information necessary to determine all applicant’s eligibility and benefit level is provided on the application for each individual in the EDG;

(B) The applicant, even if homeless, provides an address where they can receive postal mail;(C) The application is signed in accordance with section (5) of this rule; and

(D) The application is received by the Agency.

(2) General information as it relates to renewal and redetermination processing is as follows:

(a) The Authority shall review eligibility at assigned intervals, when changes are reported, and whenever a beneficiary’s eligibility becomes questionable;

(b) When renewing or redetermining medical benefits, the Agency shall, to the extent feasible, determine eligibility using information found in the beneficiary’s electronic account and electronic data accessible to the Agency;

(c) At renewal, if the Agency is unable to process an automated renewal, the Agency shall provide a pre-populated renewal form, referred to as an active renewal, to the beneficiary containing information known to the Agency, a statement of the additional information needed to renew eligibility, and the date by which the beneficiary must provide the required information in accordance with section (6) of this rule;

(d) The Agency shall assist applicants seeking assistance to complete the pre-populated renewal form or gather information necessary to renew eligibility;

(e) If the Agency provides the individual with a pre-populated renewal form to complete the renewal process, the individual must:

(A) Complete and sign the form in accordance with section (5) of this rule;

(B) Submit the form via the Internet, by telephone, via mail, in person, and through other commonly available electronic means, and

(3) A new application is required when:

(a) Except as described in section (4) of this rule, an individual who is not currently receiving HSD Medical Program benefits, and is not being added to an active HSD Medical Program benefits case, requests medical benefits;

(b) A child turns age 19, is no longer claimed as a tax dependent, and wishes to retain medical benefits;

(4) A new application is not required when:

(a) The Agency determines an applicant is not eligible in the month of application and:

(A) Is determining if the applicant is eligible the following month; or

(B) Is determining if the applicant is eligible retroactively (OAR 410-200-0130).

(b) Determining initial eligibility for HSD Medical Programs via Fast-Track enrollment pursuant to OAR 410-200-0505;

(d) An individual’s medical benefits were suspended because they became a resident of a public institution and met the requirements of OAR 410-200-0140;

(e) An individual not receiving medical program benefits is added to an existing case where any members of the individual’s EDG are receiving medical program benefits;

(f) Redetermining or renewing eligibility for beneficiaries and the Agency has sufficient evidence to redetermine or renew eligibility for the same or new program;

(g) During the ninety (90) day reconsideration period for eligibility following closure:

(A) The Authority shall redetermine in a timely manner (OAR 410-200-0110) the eligibility of an individual who:

(i) Lost HSD Medical Program eligibility because they did not return the pre-populated renewal form or respond to an RFI, and did not submit the information needed to renew eligibility; and

(ii) Within ninety (90) days of the medical closure date, submits the pre-populated renewal form or provides the requested additional information.

(B) The date the pre-populated renewal form or RFI response is submitted within the ninety (90) day reconsideration period establishes a new date of request;

(C) In the event that the pre-populated renewal form is submitted within the ninety (90) day reconsideration period and an RFI is generated for which the due date lands outside of the ninety (90) day reconsideration period, a new application is not required.

(D) If the individual is found to meet HSD Medical Program eligibility based on the completed redetermination, the effective date of medical benefits is as described in OAR 410-200-0115(3) and (4).

(5) Signature requirements are as follows:

(a) Signatures accepted by the Agency may be:

(A) Handwritten;

(B) Electronic; or

(b) An application must be signed by one of the following:

(A) The head of household;

(B) An adult in the applicant’s EDG;

(D) If the applicant is a child or incapacitated, someone age 18 or older acting responsibly for the applicant.

(c) If the original signor of an application ceases to be a member of the case, the signature of an individual described in (5(b)) of this rule is required.

(d) Hospital Presumptive Eligibility may be determined without a signature if no electronic data match with the FDSH shall be performed;

(e) At renewal, if the Agency is unable to process an automated renewal, a signature is required on the pre-populated active renewal form sent to the beneficiary.

(6) Application and renewal processing timeliness standards are as follows:

(a) At initial eligibility determination, the Agency shall inform the individual of timeliness standards, make an eligibility determination, and send a decision notice by the 45th calendar day after the Date of Request if:

(A) All information necessary to determine eligibility is present;

(B) An RFI has been issued, and the agency does not receive a response by the deadline provided; or

(b) At initial eligibility determination, the Agency may extend the 45-day period described in section (6)(a) if:

(A) The Agency must request additional information or verification, and the due date of such request extends beyond the 45th day; or

(B) There is an administrative or other emergency beyond the control of the Agency. The Agency must document the emergency;

(c) At periodic renewal of eligibility, if additional information or verification is required, the Authority shall provide the beneficiary at least thirty (30) days from the date of the renewal form to respond and provide necessary information.

(7) Individuals may apply through the FFM. If the FFM determines the individual is potentially eligible for Medicaid/CHIP or OHP Bridge, the FFM shall transfer the individual’s electronic account to the Oregon Department of Human Services for eligibility determination.

(8) HSD Medical Program eligibility is evaluated in the following order:

(a) For a child applicant:

(A) Substitute Care (OAR 410-200-0405);

(B) MAGI Parent or Caretaker Relative (OAR 410-200-0420);

(D) MAGI Child (OAR 410-200-0415);

(E) Extended Medical Assistance (OAR 410-200-0440);

(F) MAGI CHIP (OAR 410-200-0410);

(G) FFCYM (OAR 410-200-0407);

(H) BCCTP (OAR 410-200-0400)

(b) For an adult applicant:

(A) Substitute Care (OAR 410-200-0405);

(B) MAGI Parent or Caretaker Relative (OAR 410-200-0420);

(D) FFCYM (OAR 410-200-0407);

(E) MAGI Adult (OAR 410-200-0435);

(F) EXT (OAR 410-200-0440);

(G) YSHCN (OAR 410-200-0455);

(H) BCCTP (OAR 410-200-0400);

(I) OHP Bridge – Basic Medicaid (OAR 410-200-0437)

(J) OHP Bridge – Basic Health Program (OAR 410-200-0438)

(K) Compact of Free Association (COFA) Dental (OAR 410-200-0445);

(L) Veteran Dental (OAR 410-200-0450).

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 12-2023, amend filed 03/30/2023, effective 04/01/2023
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0111 Authorized Representatives

(1) With the exception of individuals who are included in the EDG solely because they are part of a tax-filers tax group (see OAR 410-200-0305) and except as limited in sections (3), (4), and (5) of this rule, the following individuals may appoint an authorized representative on a form designated by the Agency:

(a) The primary contact;

(b) An individual age 18 or older who is included in the EDG with the primary contact, head of household (see OAR 461-001-0015), or primary person (see OAR 461-001-0000), for all programs with which the primary contact, head of household, or primary person participates;

(2) The Agency shall accept an applicant or beneficiary’s designation of an authorized representative via any of the following methods that must include either a handwritten or electronic signature of both the applicant or beneficiary and designated authorized representative:

(a) The Internet;

(b) E-mail;

(d) Telephonic recording;

(e) In person; or

(f) Other electronic means.

(3) An authorized representative designated for one program is the authorized representative for all programs and benefits of the primary contact, head of household (see OAR 461-001-0015), or primary person (see OAR 461-001-0000), excluding Temporary Assistance for Domestic Violence Survivors (see OAR 461-135-1200) and long-term care services (see OAR 461-001-0000).

(4) Unless limited elsewhere in this rule, the authorized representative:

(a) May, with the exception of the Authorized Representative designation form and subject to the exception in subsection (b) of this section, complete, sign, and submit an application, renewal, or documents on the applicant’s or beneficiary’s behalf;

(b) May act on behalf of the applicant or recipient by reporting information and submitting requests to the Agency, except an individual’s long-term care (see OAR 461-001-0000) services provider cannot serve as the individual’s designated representative (see OAR 411-004-0010) or representative (see OAR 411-028-0010 and 411-030-0020) for long-term care services; and

(5) The following may not serve as an authorized representative:

(a) An individual serving an Intentional Program Violation (see OAR 461-195-0601), unless the Agency determines no one else is available to serve as the authorized representative;

(b) Homeless meal providers for homeless SNAP recipients;

(d) An individual who presents a conflict of interest;

(e) An agency employee or an employee of a contractor who is involved in the certification or issuance processes for Agency program benefits may not act as an authorized representative without the specific written approval of a designated Agency official, and only if that official determines that no one else is available to serve as an authorized representative;

(f) Retailers who are authorized to accept Department Electronic Benefit Transfer (EBT) cards may not act as an authorized representative without the specific written approval of a designated Agency official, and only if that official determines that no one else is available to serve as an authorized representative.

(6) The authorized representative must maintain the confidentiality of any information provided by the Agency regarding the represented individuals.

(7) An individual ceases to be an authorized representative when:

(a) The represented individual notifies the Agency that the designation is terminated;

(b) The represented individual appoints a different authorized representative;

(d) The Agency determines the authorized representative is no longer permitted to be the authorized representative; or

(e) There is a change in the legal authority upon which the individual or organization’s authority was based.

(8) An authorized representative may be subject to overpayments (see OAR 461-195-0501 and 461-195-0541) in addition to other penalties:

(a) In group living (see OAR 461-001-0015) arrangements or substance use disorder (SUD) treatment centers, the facility may be prosecuted under applicable federal or state law;

(b) For other authorized representatives not covered by subsection (a) of this part, the Agency may prohibit the person from serving as a representative for one year.

(9) Conditions and requirements related to the designation and administration of authorized representatives described in OAR 461-115-0090 also apply to HSD Medical Programs.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.402, 411.404, 414.534, ORS 411.400, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.536 & 414.706
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 27-2019, amend filed 06/27/2019, effective 07/01/2019
DMAP 2-2019, temporary amend filed 02/28/2019, effective 03/01/2019 through 08/26/2019
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0115 HSD Medical Programs—Effective Dates

(1) This section of the rule identifies the effective date of coverage for new applicants who are approved for HSD Medical Program benefits.

(a) For all HSD Medical programs except OHP Bridge - Basic Health Program (see OAR 410-200-0438) and the Extended Medical Assistance (EXT) program (see OAR 410-200-0440), the effective date is:

(A) The earliest date of eligibility within the month in which the Date of Request is established; or

(B) If ineligible within the month in which the Date of Request was established, the first day within the following month in which the client is determined to be eligible.

(b) For OHP Bridge - Basic Health Program:

(A) When the determination of eligibility is made on or before the 15th day of a month, the effective date of coverage is on the first day of the month following the month in which the determination was made; or

(B) When the determination of eligibility is made on or after the 16th day of a month, the effective date of coverage is the first day of the month following the next month.

(C) In accordance with the Basic Health Plan Blueprint approved by the Centers for Medicare & Medicaid Services (CMS) in June 2025, the effective date of coverage will be adjusted to January 1, 2025, if they meet all the following requirements:

(i) They were enrolled in an insurance plan through the Federally Facilitated Marketplace in December 2024;

(ii) They were referred from Federally Facilitated Marketplace to the ONE System prior to January 1, 2025;

(iii) They were not covered by an insurance plan through the Federally Facilitated Marketplace after January 1, 2025;

(iv) They were not enrolled into OHP Bridge – Basic Health Program until February 1, 2025 or later; and

(v) They request to have the effective date of coverage adjusted for the OHP Bridge - Basic Health Program no later than November 30, 2025.

(2) The effective date for retroactive medical benefits (OAR 410-200-0130) for MAGI Medicaid/CHIP and Breast and Cervical Cancer Treatment Program (BCCTP, see OAR 410-200-0400) is the earlier of:

(a) The first day of the earliest of the three (3) months preceding the month in which the Date of Request was established; or

(b) If ineligible pursuant to section (3)(a), the earliest date of eligibility within the three (3) months preceding the month in which the Date of Request was established.

(3) Renewal dates:

(a) For all HSD Medical Programs except EXT eligibility shall be renewed every twelve (12) months or upon the earliest Continuous Eligibility (CE) period end-date present on the case (see OAR 410-200-0135 Assumed, Continuous, and Protected Eligibility), whichever is later.

(b) For redeterminations that are initiated by a reported change, outside of the established renewal date, the renewal date is not adjusted.

(4) When a beneficiary reports a change in circumstances, eligibility shall be redetermined for all EDG members. When a reported change results in a:

(a) Reduction or loss of eligibility, the effective date for the change is as follows:

(A) If the determination is made on or before the 15th of the month, the first of the next month; or

(B) If the determination is made on or after the 16th of the month, the first of the month following the next month.

(b) Determination of ongoing eligibility for an HSD Medical Program at the same benefit level, the effective date of the change is:

(A) For Healthier Oregon beneficiaries (see OAR 410-200-0240) who report meeting the Citizenship and Non-Citizen Status Requirements set forth in OAR 410-200-0215, the first of the month in which the change is reported; or

(B) For all other reported changes, the first of the month following the date the change was reported.

(c) Determination of ongoing eligibility for an HSD Medical Program that is an increase in the benefit level, the effective date of the change is:

(A) For beneficiaries who report a pregnancy, the effective date of the pregnancy-related HSD Medical Program benefit is the earlier of:

(i) The first of the month in which the pregnancy is reported; or

(ii) The date that a prenatal service related to the pregnancy was received.

(B) For beneficiaries receiving coverage under the Compact of Free Association (COFA) Dental Program (OAR 410-200-0445) or Veteran Dental Program (OAR 410-200-0450) who become eligible for OHP Plus coverage, the effective date is the first of the month in which an individual meets all eligibility criteria for an OHP Plus-level HSD Medical program under OAR 410-200-0015(47)(b)-(c), 410-200-0015(47)(f)(A)-(E) and (G) or OSIPM program under OAR 461-101-0010(18).

(C) For beneficiaries receiving OHP Plus coverage who become eligible for Young Adults with Special Health Care Needs (OAR 410-200-0455), the effective date is the first of the month in which an individual meets the YSCHN health-related screening criteria as defined in Specific Requirements - Young Adults with Special Health Care Needs OAR 410-200-0455 (3)(c).

(5) Suspending or Closing Medical Benefits:

(a) The effective date for closing HSD Medical Program benefits is determined as follows:

(A) Upon the death of a beneficiary, it is the beneficiary’s date of death;

(B) When a beneficiary becomes ineligible, it is the last day of the month in which a timely continuing benefit decision notice is sent;

(C) When a beneficiary transitions from an HSD Medical Program to another program with OHP Plus level benefits, it is the day prior to the start date of those benefits;

(D) When a program ends and this is why the beneficiary is no longer eligible, it is the date the program ends;

(E) It is the last day of the month in which a basic decision notice is mailed in any of the following circumstances:

(i) A beneficiary or an individual authorized to act on the beneficiary’s behalf requests benefits be closed, and the request includes a written or recorded verbal signature; or

(ii) A beneficiary ceases to be an Oregon resident (OAR 410-200-0200) and the Agency is informed that they’re eligible for medical benefits in another state.

(F) The last day of the month in which a timely continuing benefit decision notice is sent if ongoing eligibility cannot be determined because the beneficiary does not provide required information by the deadline provided.

(b) Except for benefits obtained via Hospital Presumptive Eligibility (see OAR 410-200-0105) or a presumptive eligibility period for BCCTP (see OAR 410-200-0400), prior to closing medical benefits, the Agency shall:

(A) Determine eligibility for all other HSD Medical Programs; or

(B) Refer the beneficiary to the Department, if applicable, and confirm that the Department has made an eligibility decision.

(c) The effective date of suspension or closure for a beneficiary of HSD Medical Program benefits who become a resident of a public institution is described in Eligibility for Residents of a Public Institution OAR 410-200-0140 (2) and (3).

(6) The effective date for denying HSD Medical Program benefits is the earlier of the following:

(a) The date the decision is made that the applicant is not eligible and notice is sent; or

(b) The end of the application processing time frame, unless the time period has been extended to allow the applicant more time to provide required verification.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 2-2026, amend filed 01/26/2026, effective 01/26/2026
DMAP 76-2025, temporary amend filed 10/09/2025, effective 10/09/2025 through 04/06/2026
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 31-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0120 Notices

(1) Except as provided in this rule, the Authority shall send:

(a) A basic decision notice whenever an application for HSD Medical Program benefits is approved or denied;

(b) A timely continuing benefit decision notice whenever HSD Medical Program benefits are reduced or closed.

(2) Exceptions to the requirement to provide timely continuing decision notice when HSD Medical Program benefits are reduced or closed:

(a) When a beneficiary becomes a resident of a public institution or correctional facility, the Agency shall send a basic decision notice to close, reduce, or suspend benefits;

(b) When a beneficiary has been placed in skilled nursing care, intermediate care, or long-term hospitalization, the Agency shall send a basic decision notice to close, suspend, or reduce benefits;

(c) When returned postal mail is received without a forwarding address and the beneficiary’s whereabouts are unknown, the Authority shall send a basic decision notice to end benefits.

(d) When a beneficiary ceases to be an Oregon Resident and the Agency is informed that they’re eligible for medical benefits in another state, the Agency shall send a basic decision notice to end benefits;

(e) When a beneficiary, another adult member of the EDG, or the authorized representative requests benefits be closed, and the request includes a written or recorded verbal signature, the Agency shall send a basic decision notice to end benefits;

(f) When an individual who is not a recipient of any Medicaid/CHIP benefits makes a request to withdraw an application for benefits, the Agency shall send a basic decision notice.

(3) No decision notice is required in the following situations:

(a) The only individual in the EDG dies;

(b) A hearing was requested after a notice was received and either the hearing request is dismissed, or a final order is issued.

(4) Decision notices shall be written in plain language and be accessible to individuals who are limited English proficient and individuals with disabilities.

(5) All decision notices shall include:

(a) A statement of the action taken;

(b) A clear statement listing the specific reasons why the decision was made and the effective date of the decision;

(d) Information about the individual’s right to request a hearing and the method and deadline to request a hearing;

(e) A statement indicating under what circumstances a default order may be taken;

(f) Information about the right to counsel at a hearing and the availability of free legal services.

(6) A decision notice approving HSD Medical Program benefits, including approvals for retroactive medical, shall include:

(a) The level of benefits and services approved;

(b) If applicable, information relating to premiums, enrollment fees, and cost sharing; and

(7) A decision notice reducing, denying, or closing HSD Medical Program benefits shall include information about a beneficiary’s right to continue receiving benefits.

(8) When electronic-only is the preferred communication method, and the Agency is unable to successfully deliver an electronic notification, the Agency shall send the notice by postal mail within three business days. The date on the notice shall be the date the notice is sent by postal mail.

(9) The Authority may amend:

(a) A decision notice with another decision notice; or

(b) A contested case notice.

(10) Except as the notice is amended, or when a delay results from the client's request for a hearing, a notice to reduce or close benefits becomes void if the reduction or closure is not made effective on the date stated on the notice.

(11) The Authority shall provide individuals with a choice to receive decision notices and information referenced in this rule in an electronic format or by postal mail. If an individual chooses to receive notices and information electronically and has established an online account with the Applicant Portal of Oregon Eligibility (ONE), the Authority shall:

(a) Send confirmation of this decision by postal mail;

(b) Post notices to the individual’s electronic account within one business day of the date on the notice;

(d) At the request of the individual, send by postal mail any notice or information delivered electronically;

(e) Inform the individual of the right to stop receiving electronic notices and information and begin receiving these through postal mail; and

(f) If any electronic communication referenced above is undeliverable, send the notice by postal mail within three business days of the failed communication.

History

Statutory/Other Authority: ORS 411.402, ORS 411.404, 413.042, 414.534, 42 CFR: 431.213, 435.110, 435.112, 435.115, 435.116, 435.118, 435.940, 435.1200, 458.350, 435.3, 435.4, 435.407, 435.952, 435.1008, 457.320, 435.406, 457.380, 435.117, 435.170, 435.190, 435.916, 435.917, 435.926, 435.1205, 447.56, 457.340, 457.350, 457.360, 457.805, 433.145, 433.147, 433.148, 433.146, 435.610, 435.403, 457.80, 435.119, 435.222, 435.602, 435.608, 435.956 & 433.138
Statutes/Other Implemented: ORS 411.404, 414.534, ORS 411.400, 411.402, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.536, 414.706, 411.060, 411.095 & 414.440
DMAP 12-2023, amend filed 03/30/2023, effective 04/01/2023
DMAP 18-2021, amend filed 05/06/2021, effective 05/15/2021
DMAP 59-2020, temporary amend filed 11/17/2020, effective 11/17/2020 through 05/15/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0125 Acting on Reported Changes

(1) When an HSD Medical Program beneficiary or an individual authorized to act on the beneficiary’s behalf reports a change that may affect eligibility, the Agency shall promptly redetermine eligibility before reducing or ending medical benefits.

(2) The Agency may send an RFI to request additional information or verification related to the reported change.

(3) If a beneficiary remains eligible as a result of a redetermination due to a reported change, a new 12-month eligibility period is not established; the original renewal date is maintained.

(4) If the Authority has information about anticipated changes in a beneficiary’s circumstances that may affect eligibility, it shall redetermine eligibility at the appropriate time based on the changes.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0130 Retroactive Medical

(1) The Authority may evaluate for retroactive medical eligibility for all HSD Medical Programs, except retroactive eligibility for OHP Bridge - Basic Health Program is not permitted.

(2) The Authority shall evaluate for retroactive medical eligibility for the three calendar months preceding the month in which the Date of Request was established for the following individuals:

(a) Applicants requesting HSD Medical Programs who have unpaid medical bills or received donated medical services that may have been covered by Oregon Medicaid/CHIP; and

(b) Deceased individuals who have unpaid medical bills or received donated medical services that may have been covered by Oregon Medicaid/CHIP, who may have been eligible for Medicaid covered services had they, or someone acting on their behalf, applied.

(3) If eligible for retroactive medical, the individual’s eligibility shall not start earlier than the date indicated by OAR 410-200-0115 Effective Dates.

(4) The Authority reviews each month individually for retroactive medical eligibility.

(5) If an individual is determined to be eligible for retroactive medical eligibility, the period of retroactive eligibility shall be approved for months in which an individual received coverage during a Hospital Presumptive Eligibility period (OAR 410-200-0105), unless the retroactive benefits may be a reduction in benefit-level compared to the Hospital Presumptive Eligibility benefits.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 413.032, 414.025, 414.231, 414.534, 414.536 & 414.706
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0135 Assumed, Continuous, and Protected Eligibility

(1) Assumed Eligibility is as described below:

(a) A child born to an individual who is eligible for and receiving Medicaid/Children’s Health Insurance Program (CHIP) benefits at the time of the birth is an assumed eligible newborn (AEN);

(b) An AEN is eligible for MAGI Child benefits (OAR 410-200-0415) effective the date of birth through the end of the month in which the child turns one year of age, unless:

(A) The child dies;

(B) The child is no longer a resident of Oregon; or

(d) An AEN is entitled to assumed eligibility without providing a Social Security Number (SSN). An SSN is required to maintain coverage after the assumed eligibility period ends.

(2) Continuous Eligibility, as described below, applies to all HSD Medical programs except the OHP Bridge – Basic Health Program (OAR 410-200-0438), Extended Medical Assistance (OAR 410-200-0440), Substitute Care (OAR 410-200-0405), and Breast and Cervical Cancer Treatment Program (OAR 410-200-0400).

(a) The Continuous Eligibility (CE) period is the period of time an individual who is determined eligible for an HSD medical benefit shall maintain coverage despite changes in circumstance that may otherwise preclude eligibility, with consideration of exceptions described in section (2)(b).

(b) Coverage may be terminated during the CE period in the following circumstances:

(A) The individual is no longer an Oregon resident;

(B) The individual dies;

(D) The agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual or someone authorized to act on their behalf;

(E) An assumed eligible newborn as described in section (1) of this rule, turns age 1, and no SSN has been provided; or

(F) An individual reports a change to their Citizenship or Non-Citizen status and the information cannot be verified as outlined in OAR 410-200-0230 (2)

(c) The CE period is established when an individual is determined eligible for HSD medical benefits with no outstanding requests for information, as follows:

(A) At initial approval of eligibility, the CE period begins on the first of the month in which the individual established a Date of Request (DOR), or

(B) When approved for renewal of eligibility, the new CE period begins on the first of the month following the renewal due date.

(d) The length of the CE period is based on age and program eligibility, as follows:

(A) Children under six (6) years of age are entitled to CE through the end of the month of their sixth (6) birthday or twenty-four (24) months, whichever is later.

(B) Individuals age six (6) and above are entitled to twenty-four (24) months of CE.

(e) Except for individuals in the YSHCN program who turn 26, benefits will not be reduced or terminated during an individual’s CE period. An individual receiving YSHCN program benefits will lose the supplemental benefits described in OAR 410-200-0455(2)(a) and (b) when they turn age 26, they shall maintain OHP Plus coverage for the remainder of their CE period.

(f) If an individual’s eligibility is redetermined during the continuous eligibility period and they no longer meet:

(A) Financial eligibility requirements for any HSD Medical Program of the same or better benefit, they shall retain coverage through the program with the uppermost income eligibility threshold for which the individual meets non-financial eligibility requirements;

(B) Financial or non-financial eligibility requirements for any HSD Medical Program of the same or better benefit, they shall retain coverage through the Parent and Caretaker Relative program (OAR 410-200-0420).

(3) Protected Eligibility is as described below:

(a) Except for those individuals eligible for and receiving OHP Bridge – Basic Health Program benefits, individuals who are eligible for and receiving any HSD Medical Program benefits for any portion of their pregnancy are entitled to protected eligibility for the duration of the pregnancy and the postpartum eligibility period.

(b) The postpartum eligibility period is:

(A) Except as described in subsection (3)(b)(B), the postpartum eligibility period is twelve (12) calendar months following the month in which the pregnancy ends;

(B) For individuals who do not meet the citizen and non-citizen status requirements, who are eligible for and receiving Citizenship Waived Medical (CWM) Plus coverage for any portion of their pregnancy, the postpartum eligibility period is the two (2) calendar months following the month in which the pregnancy ends.

(A) The individual is no longer an Oregon resident;

(B) The individual dies;

(D) The agency determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual or someone authorized to act on their behalf.

History

Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038, 414.025 & 414.534
Statutes/Other Implemented: ORS 411.095, 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 44-2024, minor correction filed 02/21/2024, effective 02/21/2024
DMAP 40-2024, amend filed 02/01/2024, effective 02/01/2024
DMAP 57-2023, temporary amend filed 07/17/2023, effective 07/18/2023 through 01/12/2024
DMAP 56-2023, temporary amend filed 07/17/2023, effective 07/17/2023 through 07/17/2023
DMAP 83-2022, amend filed 11/29/2022, effective 11/29/2022
DMAP 42-2022, temporary amend filed 03/29/2022, effective 04/01/2022 through 09/27/2022
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0140 Eligibility for Residents of a Public Institution

(1) A resident of a public institution is not eligible for Health System Division (HSD) Medical Program benefits, except as follows:

(a) For individuals residing in an Institution for Mental Disease (IMD), including the Oregon State Hospital, who are:

(A) Under age 21;

(B) Age 21 if they were admitted to the IMD before their 21st birthday; or

(b) Residents of a public institution may be eligible for OHP Bridge – Basic Health Program benefits if they are awaiting disposition of charges.

(2) For all individuals enrolled in HSD Medical Programs except for OHP Bridge – Basic Health Program who become a resident of a public institution, benefits shall be suspended for the duration of the period in which the individual is a resident of that institution.

(a) The effective date of the suspension of benefits is the day following the date on which an individual becomes a resident of a public institution.

(b) Except as described in section (2)(c) of this rule, suspended benefits shall be reinstated to the same level of coverage the individual was receiving when they became a resident of a public institution effective the date on which an individual ceases to be a resident of a public institution without the need for a new application when:

(A) The Agency learns the individual is no longer a resident of a public institution within the twelve (12) calendar months following the date on which the change occurred; or

(B) The individual leaves the public institution to be admitted to a medical facility as an inpatient with an expected stay of at least 24 hours, provided the medical facility is not associated with the public institution where the individual is a resident.

(c) Individuals who were in the YSHCN program when they became a resident of a public institution and who have turned age 26 on or prior to their release date shall not have the supplemental YSHCN benefits described in OAR 410-200-0455(2)(a) and (b) reinstated upon their release.

(d) Once benefits are reinstated as described in subsection (2)(b) of this rule, a redetermination of eligibility shall be processed unless benefits are restored on a case where the existing renewal date is more than two (2) calendar months beyond the month in which the action is being taken.

(3) For individuals enrolled in OHP Bridge – Basic Health Program who become a resident of a public institution, benefits shall be terminated effective the day following the day on which they became a resident of a public institution except that coverage shall be maintained while the individual’s charges are pending disposition. In order to regain eligibility for OHP Bridge-Basic Health Program following release from the public institution, the individual must reapply.

History

Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038, 414.025 & 414.534
Statutes/Other Implemented: ORS 411.070, 411.404, 411.439, 411.443, 411.445, 411.816, 412.014, 412.049 & 414.426
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 12-2023, amend filed 03/30/2023, effective 04/01/2023
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 25-2018, amend filed 05/01/2018, effective 05/01/2018
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0145 Contested Case Hearing

(1) For the purposes of this rule, timely means within 90 days of the date the notice of adverse action is received.

(2) This rule applies to contested case hearings for programs described in OAR chapter 410 division 200, except for individuals receiving HSD Medical Program benefits during a period of Hospital Presumptive Eligibility (OAR 410-200-0105). Contested case hearings are conducted in accordance with the Attorney General's model rules OAR 137-003-0501 and following ORS Ch. 183 except to the extent that Authority rules provide for different procedures.

(3) The Authority’s contested case hearings governed by this rule are not open to the public and are closed to nonparticipants, except nonparticipants may attend subject to the parties' consent and applicable confidentiality laws.

(4) A claimant may request a contested case hearing upon the timely completion of a hearing request in medical assistance programs in the following situations:

(a) The Authority has not approved or denied an application within 45 days of the date of request for benefits or the extended time the Authority has allowed for processing;

(b) The Authority acts to deny, reduce, close, or suspend medical assistance, including the denial of continued benefits pending the outcome of a contested case hearing;

(d) A claimant claims that the Authority previously under issued medical assistance;

(e) A claimant disputes the current level of benefits.

(5) An officer or employee of the Authority or the Department of Human Services may appear on behalf of the Authority in medical assistance hearings described in this rule. The Authority’s lay representative may not make legal argument on behalf of the Authority.

(6) The Authority representative is subject to the Code of Conduct for Non-Attorney Representatives at Administrative Hearings, which is maintained by the Oregon Department of Justice and available on its website at http://www.doj.state.or.us. An Authority representative appearing under this rule shall read and be familiar with it.

(7) When an Authority representative is used, requests for admission and written interrogatories are not permitted.

(8) The Authority representative and the claimant may have an informal conference in order to:

(a) Provide an opportunity to settle the matter;

(b) Review the basis for the eligibility determination, including reviewing the rules and facts that serve as the basis for the decision;

(c) Exchange additional information that may correct any misunderstandings of the facts relevant to the eligibility determination; or

(d) Consider any other matters that may expedite the orderly disposition of the hearing.

(9) A claimant who is receiving medical assistance benefits and who is entitled to a continuing benefit decision notice may, at the option of the claimant, receive continuing benefits in the same manner and amount until a final order resolves the contested case. In order to receive continuing benefits, a claimant must request a hearing not later than:

(a) The tenth day following the date the notice is received; and

(b) The effective date of the action proposed in the notice.

(10) The continuing benefits are subject to modification based on additional changes affecting the claimant’s eligibility or level of benefits.

(11) The claimant shall receive an expedited hearing in the following situations:

(a) When the claimant contests the denial of continuing benefits; or

(b) When following the final order timelines in OAR 410-200-0146 could jeopardize the individual’s life, health, or ability to attain, maintain, or regain maximum function.

(12) In computing timeliness under sections (1) and (9) of this rule:

(a) The agency follows criteria outlined in 461-125-0310(7); and

(b) The notice is considered to be received on the fifth day after the notice is sent unless the claimant shows the notice was received later or was not received.

History

Statutory/Other Authority: ORS 411.404, 411.816, 412.014, 412.049 & 413.042
Statutes/Other Implemented: ORS 183.452, 411.060, 411.404, 411.816, 412.014 & 412.049
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 33-2019, amend filed 08/23/2019, effective 08/23/2019
DMAP 13-2019, temporary amend filed 05/23/2019, effective 07/01/2019 through 12/27/2019
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 50-2014(Temp), f. 8-14-14, cert. ef. 8-15-14 thru 2-11-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0146 Final Orders, Dismissals and Withdrawals

(1) When the Authority refers a contested case under chapter 410 division 200 to the Office of Administrative Hearings (OAH), the Authority must indicate on the referral:

(a) Whether the Authority is authorizing a proposed order, a proposed and final order, or a final order; and

(b) If the Authority establishes an earlier deadline for written exceptions and argument because the contested case is being referred for an expedited hearing.

(2) When the Authority authorizes either a proposed order or a proposed and final order:

(a) The claimant may file written exceptions and written argument to be considered by the Authority. The exceptions and argument must be received at the location indicated in the OAH order not later than the 20th day after service of the proposed order or proposed and final order, unless section (1)(b) of this rule applies;

(b) The Authority shall issue the final order after OAH issues a proposed order unless the Authority requests that OAH issue the final order pursuant to OAR 137-003-0655.

(c) The proposed and final order becomes a final order on the 21st day after the service of the proposed and final order, if the claimant does not submit timely exceptions or arguments following a proposed and final order, unless:

(A) The Authority has issued a revised order; or

(B) The Authority has notified the claimant and OAH that the Authority shall issue the final order.

(d) The Authority shall issue the final order when the Authority receives timely exceptions or argument unless the Authority requests that OAH issue the final order.

(3) In a contested case hearing, if the OAH is authorized to issue a final order on behalf of the Authority, the Authority may issue the final order in the case of default.

(4) A petition by a claimant for reconsideration or rehearing must be filed with the individual who signed the final order unless stated otherwise on the final order.

(5) A final order is effective immediately upon being signed or as otherwise provided in the order. Delay due to a postponement or continuance granted at the claimant’s request may not be counted in computing time limits for a final order. A final order shall be issued or the case otherwise shall be resolved no later than:

(a) Ninety days following the date of the hearing request;

(b) Three working days after the date the OAH hears an expedited hearing.

(6) In the event a request for a hearing is not timely or the claimant has no right to a contested case hearing on an issue, and there are no factual disputes about whether this division of rules provides a right to a hearing, the Authority may issue an order accordingly. The Authority may refer an untimely request to the OAH for a hearing on timeliness or on the question of whether the claimant has the right to a contested case hearing.

(7) If the Authority serves a decision notice on the claimant by postal or electronic mail and the Authority receives an untimely hearing request from the claimant within 75 days from the date the decision notice became a final order, then one of the following shall occur:

(a) If the Authority finds that the claimant did not receive the decision notice and did not have actual knowledge of the notice, the Authority shall refer the hearing request to the OAH for a contested case hearing on the merits of the Authority’s action described in the notice; or

(b) If there is a factual dispute regarding the claimant’s receipt or knowledge of the notice, the Authority shall refer the hearing request to the OAH for a contested case hearing to determine whether the claimant received or had actual knowledge of the notice. The Authority has the burden to prove by a preponderance of the evidence that the claimant had actual knowledge of the notice or that the Authority mailed the notice to the claimant’s correct mailing address or sent an electronic notice to the claimant’s correct electronic mail address according to the information the claimant provided to the Authority.

(8) If the Authority receives an untimely hearing request from the claimant, regardless of the manner in which the Authority served the decision notice on the claimant, then:

(a) If the Authority finds that the claimant’s hearing request was untimely for good cause as defined in OAR 137-003-0501(7), the Authority shall refer the hearing request to the OAH for a contested case hearing on the merits of the Authority’s action described in the notice; or

(b) If there is a factual dispute regarding the existence of good cause, the Authority shall refer a hearing request to the OAH for a contested case hearing to determine whether there was good cause as defined in OAR 137-003-0501(7) for the claimant’s delay in submitting the hearing request to the Authority.

(d) The Authority may dismiss a hearing request as untimely if the claimant does not qualify for a hearing under sections (8)(a), (b), or (c).

(9) A claimant may withdraw a hearing request at any time before a final order has been issued on the contested case. When a claimant withdraws a hearing request:

(a) The Authority shall send an order confirming the withdrawal to the claimant’s last known address;

(b) The claimant may cancel the withdrawal in writing. The withdrawal must be received by the Authority hearing representative no later than the tenth working day following the date the Authority sent the order confirming the withdrawal.

(10) A hearing request is dismissed by order by default when neither the claimant nor the claimant’s representative appears at the time and place specified for the hearing. The order is effective on the date scheduled for the hearing. The Authority shall cancel the dismissal order on request of the claimant on a showing that the claimant was unable to attend the hearing and unable to request a postponement due to circumstances meeting the good cause criteria described in OAR 137-003-0501(7).

History

Statutory/Other Authority: ORS 183.341, 413.042, 411.060, 411.404, 411.408, 411.816, 412.014 & 412.049
Statutes/Other Implemented: ORS 183.341, 411.060, 411.404, 411.408, 411.816, 412.014 & 412.049
DMAP 33-2019, amend filed 08/23/2019, effective 08/23/2019
DMAP 13-2019, temporary amend filed 05/23/2019, effective 07/01/2019 through 12/27/2019
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 50-2014(Temp), f. 8-14-14, cert. ef. 8-15-14 thru 2-11-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0200 Residency Requirements

(1) To be eligible for HSD Medical Programs, an individual must be a resident of Oregon.

(2) An individual is a resident of Oregon if the individual lives in Oregon except:

(a) An individual 21 years of age or older who is placed in a medical facility in Oregon by another state is considered to be a resident of the state that makes the placement if:

(A) The individual is capable of indicating intent to reside; or

(B) The individual became incapable of indicating intent to reside after attaining 21 years of age (see section (c) of this part).

(b) For an individual less than 21 years of age who is incapable of indicating intent to reside or an individual of any age who became incapable of indicating that intent before attaining 21 years of age, the state of residence is one of the following:

(A) The state of residence of the individual's parent or legal guardian at the time of application;

(B) The state of residence of the party who applies for benefits on the individual's behalf if there is no living parent or the location of the parent is unknown, and there is no legal guardian;

(C) Oregon, if the individual has been receiving medical assistance in Oregon continuously since November 1, 1981, or is from a state with which Oregon has an interstate agreement that waives the residency requirement;

(D) When a state agency of another state places the individual, the individual is considered to be a resident of the state that makes the placement.

(c) An individual is presumed to be incapable of indicating intent to reside if the individual falls under one or more of the following:

(A) The individual is assessed with an IQ of 49 or less based on a test acceptable to the Authority;

(B) The individual has a mental age of seven years or less based on tests acceptable to the Authority;

(D) The individual is found incapable of indicating intent to reside based on documentation provided by a physician, psychologist, or other professional licensed by the State of Oregon in the field of intellectual disabilities.

(3) There is no minimum amount of time an individual must live in Oregon to be a resident. The individual is a resident of Oregon if:

(a) The individual intends to remain in Oregon; or

(b) The individual entered Oregon with a job commitment or is looking for work.

(4) An individual is not a resident if the individual is in Oregon solely for a vacation.

(5) An individual continues to be a resident of Oregon during a temporary period of absence if they intend to return when the purpose of the absence is completed.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0205 Concurrent and Duplicate Program Benefits

(1) An individual receiving HSD Medical Program benefits may not receive the following medical benefits at the same time except as described in section (3) of this rule:

(a) Any other HSD Medical Program;

(b) Office of Child Welfare Medical;

(d) Oregon Supplemental Income Program-Medical (OSIPM); or

(e) Refugee Medical Assistance (REFM).

(2) An individual may not receive HSD Medical Program benefits and medical benefits from another state unless the individual’s provider refuses to submit a bill to the Medicaid/CHIP agency of the other state and the individual would not otherwise receive medical care.

(3) Individuals may receive the supplemental YSHCN program benefits as described in OAR 410-200-0455(2)(a) and (b) concurrent with the MAGI Medicaid/CHIP programs defined in OAR 410-200-0015(d) and 410-200-0015(f)(A)-(E), and OSIPM programs as defined in OAR 461-101-0010(18).

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0210 Requirement to Provide Social Security Number

(1) The Agency may collect a Social Security Number (SSN) for the following purposes:

(a) The determination of eligibility for benefits. The SSN is used to verify income and other assets and to match with other state and federal records such as the Internal Revenue Service (IRS), Medicaid, spousal support, Social Security benefits, and unemployment benefits;

(b) The preparation of aggregate information and reports requested by funding sources for the program providing benefits;

(d) Conducting quality assessment and improvement activities;

(e) Verifying the correct amount of payments, recovering overpaid benefits, and identifying any individual receiving benefits in more than one household.

(2) As a condition of eligibility, except as provided in section (6) below, each applicant (including children) requesting medical benefits shall:

(a) Provide a valid SSN; or

(b) Apply for an SSN if the individual does not have one and provide the SSN when it is received.

(3) The agency may not deny or delay services to an otherwise eligible individual pending issuance or verification of the individual’s SSN or if the individual meets one of the exceptions identified in section (6).

(4) Except as provided in section (6) below, if an applicant does not recall their SSN or has not been issued an SSN and the SSN is not available to the Agency, the Agency shall:

(a) Obtain required evidence under SSA regulations to establish the age, the citizenship, or non-citizen status and the true identity of the applicant; and

(b) Either assist the applicant in completing an application for an SSN or, if there is evidence that the applicant has previously been issued an SSN, request SSA to furnish the number.

(5) The Agency may request that non-applicants provide an SSN on a voluntary basis. The Agency shall use the SSN for the purposes outlined in section (1).

(6) An applicant is not required to apply for or provide an SSN if the individual:

(a) Does not have an SSN and the SSN may be issued only for a valid-non-work reason;

(b) Is not eligible to receive an SSN;

(c) Is a member of a religious sect or division of a religious sect, and the individual adheres to its tenets or teachings, and for that reason is opposed to applying for or using a national identification number; or

(d) Is a newborn that is assumed eligible based on the eligibility of the mother of the newborn and who is under one year of age.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 413.032, 413.038, 414.025, 414.231, 414.534, 414.536 & 414.706
DMAP 60-2025, amend filed 08/08/2025, effective 08/15/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0215 Citizenship and Non-Citizen Status Requirements

(1) To meet the citizenship requirement for an HSD Medical Program, an individual must be:

(a) A citizen of the United States; or

(b) A citizen of Puerto Rico, Guam, the Virgin Islands or Saipan, Tinian, Rota or Pagan of the Northern Mariana Islands; or

(2) For the purposes of this rule, a Qualified Non-Citizen (QNC) is an individual who is:

(a) A non-citizen lawfully admitted for permanent residence under the INA (8 U.S.C. 1101 et seq);

(b) A non-citizen paroled into the United States under section 212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) for a period of at least one (1) year;

(c) A battered spouse or child who meets the requirements of 8 U.S.C. 1641(c) as determined by the U.S. Citizenship and Immigration Services;

(d) A non-citizen granted conditional entry pursuant to section 203(a)(7) of the INA (8 U.S.C. 1153(a)(7)) as such statute was in effect prior to April 1, 1980;

(e) A refugee admitted to the United States as a refugee under section 207 of the INA (8 U.S.C. 1157);

(f) A non-citizen granted asylum under section 208 of the INA (8 U.S.C. 1158);

(g) A non-citizen whose deportation is being withheld under section 243(h) of the INA (8 U.S.C. 1253(h)) (as in effect immediately before April 1, 1997) or section 241(b)(3) of the INA (8 U.S.C. 1231(b)(3)) (as amended by section 305(a) of division C of the Omnibus Consolidated Appropriations Act of 1997, Pub. L. No. 104-208, 110 Stat. 3009-597 (1996));

(h) A non-citizen who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980);

(i) An Afghan or Iraqi non-citizen granted Special Immigration Status (SIV) as defined in section 101(a)(27) of the INA;

(j) Effective December 28, 2020, an individual lawfully residing in the United States in accordance with the Compacts of Free Association (i.e., the governments of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau);

(k) An individual granted immigration status under section 584(a) of the Foreign Operations, Export Financing and Related Program Appropriations Act of 1988;

(l) A "victim of a severe form of trafficking in persons" certified under the Victims of Trafficking and Violence Protection Act of 2000 (22 U.S.C. 7101 to 7112); or

(m) A family member of a victim of a severe form of trafficking in persons who holds a visa for family members authorized by the Trafficking Victims Protection Reauthorization Act of 2003 (22 U.S.C. 7101 to 7112).

(3) For the purposes of this rule, an individual is Lawfully Present as described below:

(a) For the MAGI Medicaid/CHIP programs:

(A) A QNC

(B) A non-citizen with a valid non-immigrant status, as defined in 8 USC 1101(a)(15) or as otherwise defined under other United States immigration laws (as defined in 8 USC 1101(a)(17));

(C) A non-citizen who has been paroled into the United States in accordance with 8 USC 1182(d)(5) for less than one (1) year, provided they have not been paroled for prosecution, for deferred inspection, or pending removal proceedings;

(D) A non-citizen who belongs to one of the following classes of non-citizens:

(i) Granted temporary resident status in accordance with 8 USC 1160 or 1255a;

(ii) Granted temporary protected status (TPS) in accordance with 8 USC 1254a and individuals with a pending application for TPS who have been granted employment authorization;

(iii) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101–649, as amended;

(iv) Under Deferred Enforced Departure (DED) pursuant to a decision made by the President;

(v)  Granted Deferred Action status; or

(vi)  Beneficiary of approved visa petition who has a pending application for adjustment of status.

(E) An individual with a pending applicant for asylum under 8 U.S.C. 1158, or for withholding of removal under section 8 U.S.C.  1231, or under the Convention Against Torture who:

(i) Has been granted employment authorization, or

(ii) Is under the age of 14 and has had an application pending for at least 180 days;

(F) Has been granted withholding of removal under the Convention Against Torture;

(G) A child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.  1101(a)(27)(J);

(H) A non-citizen who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C.  1806(e); or

(I) A non-citizen who is lawfully present in American Samoa under the immigration laws of American Samoa.

(b) For the OHP Bridge – Basic Health Program:

(A) A QNC

(B) A non-citizen with a valid non-immigrant status, as defined in 8 USC 1101(a)(15) or as otherwise defined under other United States immigration laws (as defined in 8 USC 1101(a)(17));

(D) A non-citizen who belongs to one of the following classes of non-citizens:

(i) Granted temporary resident status in accordance with 8 USC 1160 or 1255a;

(ii) Granted temporary protected status (TPS) in accordance with 8 USC 1254a

(E) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101–649, as amended; or section 1504 of the LIFE Act Amendments of 2000, title XV of H.R. 5666, enacted by reference in Pub. L. 106-554 (see section 1504 of App. D to Pub. L. 106-554);

(F) Under Deferred Enforced Departure (DED) pursuant to a decision made by the President;

(G) Granted Deferred Action status, with the following exception:

(i) Through August 24, 2025, individuals granted deferred action under 8 CFR 236.22 are considered Lawfully Present for the sake of eligibility for the OHP Bridge – Basic Health Program;

(ii) Effective August 25, 2025, individuals granted deferred action under 8 CFR 236.22 are not considered Lawfully Present for the sake of eligibility for the OHP Bridge – Basic Health Program.

(H) Has a pending application for adjustment of status;

(I) Is an individual under the age of 14 and has a pending application for asylum under 8 U.S.C. 1158, for withholding of removal under 8 U.S.C. 1231(b)(3)(A), or for protection under the regulations implementing the Convention Against Torture;

(J) Has been granted withholding of removal under the Convention Against Torture;

(K) Has a pending or approved petition for Special Immigrant Juvenile classification as described in 8 U.S.C. 1101(a)(27)(J).

(L) A non-citizen who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C.  1806(e); or

(M) A non-citizen who is lawfully present in American Samoa under the immigration laws of American Samoa.

(4) To meet the non-citizen status requirements for MAGI Medicaid/CHIP programs, an individual must meet at least one of the following:

(a) Is a QNC as described in (2)(d) - (2)(m) of this rule; or,

(b) For the period of July 31, 2021 through March 31, 2023, or through the end of the individual’s parole, whichever is later:

(A) Be a citizen or national of Afghanistan who is paroled into the US between July 31, 2021 through September 30, 2023;

(B) Be a spouse of an individual described in (4)(b)(A); or

(c) Effective February 24, 2022, the individual is a citizen or national of Ukraine, or if not a citizen or national of Ukraine but had been habitually residing in Ukraine when they:

(A) Were paroled into the United States between February 24, 2022 and September 30, 2023 and their parole has not been terminated; or

(B) Were paroled into the United States after September 30, 2023, their parole has not been terminated; and —

(i) they are the spouse or child of an individual described in subsection (4)(c)(A); or

(ii) they are the parent, legal guardian, or primary caregiver of an individual described in section (4)(c)(A) who is determined to be an unaccompanied child under section 462(g)(2) of the Homeland Security Act of 2002 (6 USC 279(g)(2)) or section 412(d)(2)(B) of the Immigration and Nationality Act (8 USC 1522(d)(2)(B)).

(d) An individual who is under the age of 19 and who is Lawfully Present as described in section (3)(a) of this rule;

(e) An individual who is 19 or older, and is a QNC as described in (2)(a)-(c) of this rule and who meets at least one of the following:

(A) Was a QNC prior to August 22, 1996;

(B) Obtained the status described in section (2)(a)-(c) of this rule at least five (5) years before the request for benefits;

(C) Physically entered the United States before August 22, 1996 and was continuously present in the United States between August 22, 1996 and the date qualified non-citizen status was obtained. An individual is not continuously present in the United States if the individual is absent from the United States for more than thirty (30) consecutive days or a total of more than ninety (90) days between August 22, 1996, and the date qualified non-citizen status was obtained;

(D) Is a member of the United States Armed Forces on active duty (other than active duty for training);

(E) Is a veteran of the United States Armed Forces who was honorably discharged for reasons other than noncitizen status and who fulfilled the minimum active-duty service requirements described in 38 USC 5303A(d); or

(F) Is the child or spouse, including an un-remarried surviving spouse, of an individual described in section (4)(e)(D) or (4)(e)(E) of this subsection.

(5) To meet the non-citizen status requirements for OHP Bridge - Basic Health Program an individual must be:

(a) Lawfully Present as described in (3)(b) of this rule,

(b) An individual as described in (4)(b) or (4)(c) of this rule.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 414.534, 42 CFR: 435.110, 435.112, 435.115, 435.116, 435.118, 435.403, 435.940, 435.1200, 457.80, 457.340, 458.350, 435.3, 435.4, 435.406, 435.407, 435.940, 435.952, 435.956, 435.1008, 457.320, 457.380, 435.117, 435.170, 435.190, 435.916, 435.917, 435.926, 435.1205, 447.56, 457.350, 457.360, 457.805, 433.145, 433.148, 433.146, 435.610, 435.119, 435.222, 433.138, 433.147, 435.602, 435.608, 89 FR 39392 & 45 CFR: 155.20
Statutes/Other Implemented: ORS 411.402, 411.404, 414.534, 411.400, 411.406, 413.032, 414.025, 414.231, 414.536, 414.706, 411.439, 411.443, 413.038, 414.231 & 414.440
DMAP 77-2025, amend filed 10/23/2025, effective 10/23/2025
DMAP 64-2025, temporary amend filed 08/28/2025, effective 08/28/2025 through 10/26/2025
DMAP 44-2025, temporary amend filed 04/30/2025, effective 04/30/2025 through 10/26/2025
DMAP 132-2024, temporary amend filed 10/31/2024, effective 11/01/2024 through 04/29/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 38-2023, amend filed 04/28/2023, effective 04/28/2023
DMAP 85-2022, amend filed 11/29/2022, effective 11/29/2022
DMAP 66-2022, temporary amend filed 07/13/2022, effective 07/13/2022 through 01/08/2023
DMAP 37-2021, amend filed 09/15/2021, effective 09/15/2021
DMAP 11-2021, temporary amend filed 03/22/2021, effective 03/22/2021 through 09/17/2021
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0225 Assignment of Rights

The requirements of this rule apply to all Health Systems Division Medical Programs except for the OHP Bridge – Basic Health Program, Compact of Free Association (COFA) Dental Program, and Veteran Dental Program.

(1) As a condition of eligibility, the applicant, beneficiary, or person legally responsible for the applicant or beneficiary must cooperate with the Agency to:

(a) Identify any third party liable or potentially liable for medical costs paid by the Agency, Coordinated Care Organization (CCO), or prepaid managed care health services organization to, or on behalf of, an individual or any individual applying for or receiving medical assistance;

(b) Provide information about liability of third parties or other insurance that may cover or pay for medical costs paid by the Agency, CCO, or prepaid managed care health services organization to or on behalf of a medical assistance applicant or recipient;

(c) Provide other information as required by the CCO or prepaid managed care health services organization to assist in pursuing payment from any third party who may be liable for medical costs paid by the Agency, CCO, or prepaid managed care health services organization to or on behalf of a medical assistance applicant or recipient;

(d) Comply with the personal injury claim provisions in accordance with OAR 461-195-0303 and 461-195-0310.

(2) As a condition of eligibility, the applicant, beneficiary, or person legally responsible for the applicant or beneficiary must cooperate with the Agency to assign their rights to third party payments as follows:

(a) Assign to the Agency any rights of each household member receiving benefits to reimbursement for medical care costs to the Agency including any third party payments for medical care and any medical care support available under an order of a court or an administrative agency;

(b) Assign to the Agency any rights to payment for medical care from any third party and, once they receive assistance, to assist the Agency in pursuing any third party who may be liable for medical care or services paid by the Agency, including health services paid for pursuant to ORS 414.706 to 414.774 as set forth in OAR 461-195-0303 and 461-195-0310; and

(c) Except for eligibility granted under Healthier Oregon (OAR 410-200-0240) or during a period of Hospital Presumptive Eligibility (OAR 410-200-0105):

(A) An applicant shall assign to the state the right of any Medicaid-eligible individual in the household to receive any cash medical support that accrues while the individual receives assistance, not to exceed the total amount of assistance paid; and

(B) Cash medical support received by the Agency shall be retained as necessary to reimburse the Agency for medical assistance payments made on behalf of an individual with respect to whom such assignment was executed.

(C) Each caretaker who is legally able shall assist the Agency and the Oregon Child Support Program (OCSP) in establishing paternity for each child receiving medical assistance and in obtaining an order directing the non-custodial parent of a child receiving benefits to provide cash medical support or health care coverage for that child

(3) The signature of the applicant, person legally responsible for the applicant, or authorized representative on the application for assistance signifies the applicant’s agreement to cooperate with the Agency and assign the rights to reimbursement for medical care costs to the Agency.

(4) To the extent that payment for covered expenses has been made under the state medical assistance program for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by any other party for those health care items or services. This assignment of rights is automatic in accordance with ORS 659.830 and 743B.470 and does not require the consent of any individual.

(5) The individual who is legally able to cooperate and assign rights, including a caretaker who has the authority to cooperate and assign rights on behalf of a child applying for or receiving Medicaid/CHIP and fails to do so, is ineligible for assistance until the requirements of this rule are met or unless good cause exists. An individual is considered to have good cause if any of the following are true:

(a) Cooperation may result in emotional or physical harm;

(b) Other good cause reasons exist; or

(c) In addition to subsections (5)(a) and (5)(b), for individuals with the legal authority to pursue child support on behalf of a child who is applying for or receiving Medicaid benefits:

(A) The child was conceived as a result of incest or rape and efforts to obtain support may be detrimental to the child.

(B) Legal proceedings are pending for adoption of the child;

(C) The parent is being helped by a public or licensed private social agency to resolve the issue of whether to release the child for adoption; or

(D) The individual is pregnant.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 411.060, 411.033, 411.034 & 411.085
Statutes/Other Implemented: ORS 411.402, 411.404, 411.406, 413.032, 414.025, 414.231, 414.706, 411.400, 416.510, 416.520 & 416.530
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 46-2025, temporary amend filed 06/02/2025, effective 06/03/2025 through 11/29/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0230 Verification

(1) Applicants, beneficiaries, or an individual authorized to act on their behalf shall attest to the following information:

(a) Age and date of birth;

(b) Application for other benefits;

(d) Household composition;

(e) Legal name;

(f) Medicare;

(g) Pregnancy;

(h) Receipt or availability of other healthcare coverage;

(i) Residency;

(j) Social Security number; and

(k) American Indian/Alaska Native status.

(2) Applicants, beneficiaries, or individuals authorized to act on their behalf shall make a declaration of US citizenship, US national, or non-citizen status;

(a) Self-attested information shall be verified via the federal data services hub (FDSH) or by electronic verification source available to the Agency;

(b) In the event that attested status cannot be verified via the FDSH or by electronic verification sources available to the Agency, self-attested information shall be used to determine eligibility, and the individual provided a reasonable opportunity period to provide verification of US citizen, US national, or non-citizen status as outlined in section (e) of this part. Exceptions to this verification requirement are described in sections (c) and (d) of this part

(c) Applicants or beneficiaries attesting to US citizenship are exempt from the requirement to verify their citizenship if they are one of the following:

(A) Individuals who are assumed eligible (OAR 410-200-0135);

(B) Individuals who are entitled to or enrolled in Medicare;

(C) Individuals who are presumptively eligible for the BCCTP program through the BCCTP screening program or through the Hospital Presumptive Eligibility process (OAR 420-200-0400 and 410-200-0105);

(D) Individuals receiving Social Security Disability Income (SSDI); or

(E) Individuals whose citizen status was previously documented by the Agency. The Agency may not re-verify or require an individual to re-verify citizenship at a renewal of eligibility or subsequent application following a break in coverage.

(d) Applicants or beneficiaries age 19 and older who attest to having an immigration status that is not a qualified non-citizen status (see OAR 410-200-0215(2)) are exempt from the requirement to verify non-citizen status;

(e) US Citizen, US National, and Non-citizen status verification guidelines:

(A) Individuals attesting to US citizenship shall verify their status by submitting any of the documents permitted under section 1903(x) of the Social Security Act (42 U.S.C. 1396b);

(B) Individuals attesting to non-citizen status shall verify their status by:

(i) Submitting documentation or other proof from the Immigration and Naturalization Service which contains the individual’s U.S. Citizenship and Immigrations Services (USCIS) number (or numbers if the individual has more than one number); or

(ii) Submitting other documents the State determines constitutes reasonable evidence indicating a satisfactory immigration status.

(f) For individuals with a qualified non-citizen status (see OAR 410-200-0215(2)), the Agency shall not require verification of the following unless questionable:

(A) Attestation to being continuously present in the U.S. since August 22, 1996;

(B) Attestation to being an honorably discharged veteran or in active military duty status; and

(C) Attestation to being the spouse or unmarried dependent child of an individual identified in subsection (B) of this part.

(g) Non-citizen status shall be reviewed and verified at the following times:

(A) Initial determination of eligibility;

(B) When a report of change of non-citizen status is received by the Agency.

(3) Applicants, beneficiaries, or individuals authorized to act on their behalf shall make a declaration of income:

(a) If the attested income exceeds the threshold that would produce eligibility for all EDG members, the Authority shall accept the attested information, deny HSD Medical Programs, and refer to the Federally Facilitated Marketplace for potential APTC eligibility;

(b) Attested income that would result in eligibility for one or more EDG members is compared to documentary evidence through a match with the FDSH or electronic verification sources available to the Agency. The attestation is considered reasonably compatible, and thus does not require further verification if:

(A) Income information obtained via FDSH or other available electronic verification sources is not discrepant by more than 10% when compared to the attestation; or

(B) Both the attested income and information obtained via FDSH or other available electronic verification sources are within the income threshold for the same HSD Medical Program.

(c) In the event that attested income is not reasonably compatible with information obtained via the FDSH or electronic verification sources available to the agency, prior to the determination of eligibility the agency will:

(A) Request documentary verification of income from the individual; or

(B) If the individual cannot obtain verification of income, a reasonable explanation as to why.

(4) Applicants, beneficiaries, or individuals authorized to act on their behalf shall make a declaration of receipt of private health insurance:

(a) Self-attested information shall be used to determine eligibility for HSD Medical Programs if:

(A) Information obtained through a match with the FDSH or electronic verification sources available to the agency does not conflict with attested information;

(B) Information obtained through a match with available electronic data conflicts with attested information but does not affect eligibility; or

(C) Verification is not available via a match with available electronic data or by any other method at the time of application processing.

(b) In the event that information obtained through a match with the FDSH or electronic verification sources available to the agency conflicts with attested information and may affect eligibility, private health insurance information shall be verified prior to eligibility determination.

(5) The Authority may request that applicants and beneficiaries of medical assistance provide additional information, including documentation, to verify most eligibility criteria if attested information is questionable or a discrepancy is identified.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 84-2022, amend filed 11/29/2022, effective 11/29/2022
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0235 Changes That Must Be Reported

(1) Reporting requirements described in this rule apply to any individual whose information is considered in determining eligibility for any case member.

(2) An individual or someone authorized to act on the individual’s behalf shall report the following changes in circumstances within 10 calendar days of its occurrence:

(a) The receipt or loss of health care coverage;

(b) A change in mailing or residential address;

(d) A change in pregnancy status;

(e) A change in tax-filing status;

(f) A change in citizenship or immigration status of an applicant or recipient;

(g) Someone joins or permanently leaves the household;

(h) Someone becomes a resident of a public institution;

(i) For all HSD Medical Programs except MAGI CHIP, a change in availability of employer-sponsored health insurance;

(j) For the MAGI Parent or Caretaker Relative and EXT programs, when the beneficiary no longer has a dependent child living in the home, including:

(A) The only dependent child leaves the household; or

(B) The only dependent child is 18 years old and not a full-time student in a secondary school or equivalent vocational or technical training.

(k) An EDG member age 19 or older experiences a change in income, including:

(A) A change in source of income;

(B) A change in employment status:

(i) For a new job, the change occurs the first day of the new job;

(ii) For a job separation, the change occurs on the last day of employment.

(C) A change in earned income more than $100 per month. The change occurs upon the receipt by the beneficiary of the first paycheck from a new job or the first paycheck reflecting the updated income amount;

(D) A change in unearned income more than $50 per month. The change occurs the day the beneficiary receives the new or changed payment.

(3) Individuals shall report a claim or action for personal injury within 10 calendar days of its occurrence in accordance with OAR 461-195-0303 and 461-195-0310.

(4) Changes may be reported via the Internet, by telephone, via mail, in person, and through other commonly available electronic means.

(5) A change is considered reported on the date the information is received by the Agency.

(6) A change reported for one program is considered reported for all programs administered by the Agency in which the beneficiary participates.

(7) The following changes are not required to be reported:

(a) Periodic cost-of-living adjustments to the federal Black Lung Program, SSB, SSDI, SSI, and Veterans’ assistance under Title 38 of the United States Code;

(b) Changes in eligibility criteria based on legislative or regulatory actions.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 12-2023, amend filed 03/30/2023, effective 04/01/2023
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0240 Healthier Oregon and Citizenship Waived Medical and Citizenship Waived Medical Plus Benefits

(1) Healthier Oregon:

(a) Healthier Oregon benefits include Cover All Kids as of July 1, 2022, and are equal to OHP Plus benefits as defined in OAR 410-120-1210.

(b) Effective July 1, 2023, individuals are eligible for Healthier Oregon benefits if they:

(A) Meet all eligibility requirements for an HSD Medical Program; and

(B) Do not meet the Citizenship and Non-Citizen Status Requirements set forth in OAR 410-200-0215;

(A) Age 0 through 25 or age 55 and older;

(B) Met all eligibility requirements for an HSD Medical Program; and

(2) Citizenship Waived Medical (CWM) and Citizenship Waived Medical Plus (CWM Plus):

(a) Individuals eligible for CWM and CWM Plus through June 30, 2023, received benefits as defined in OAR 410-134-0005(2).

(b) To be eligible for CWM benefits, an individual must have:

(A) Been age 26 or older and under age 55;

(B) Met all eligibility requirements for an HSD Medical Program; and

(c) To be eligible for CWM Plus benefits, an individual must have met the CWM eligibility requirements described in section (b) of this rule and must have been pregnant or in their protected postpartum eligibility period as described in OAR 410-200-0135(3)(b)(B).

History

Statutory/Other Authority: ORS 411.060, 411.402, 411.404, 413.042, 414.025 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 414.534, 414.536 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 83-2022, amend filed 11/29/2022, effective 11/29/2022
DMAP 65-2022, amend filed 06/30/2022, effective 07/01/2022
DMAP 42-2022, temporary amend filed 03/29/2022, effective 04/01/2022 through 09/27/2022
DMAP 30-2022, minor correction filed 02/16/2022, effective 02/16/2022
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 86-2018, amend filed 08/23/2018, effective 09/11/2018
DMAP 24-2018, temporary amend filed 04/27/2018, effective 04/29/2018 through 10/25/2018
DMAP 23-2018, amend filed 04/27/2018, effective 04/29/2018
DMAP 44-2017, temporary amend filed 11/01/2017, effective 11/01/2017 through 04/29/2018
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0305 Eligibility Determination Group — Health System Division Medical Programs.

(1) When establishing eligibility for MAGI Medicaid/CHIP, each applicant or beneficiary shall have their own Eligibility Determination Group (EDG) determined individually based on the following EDG rules:

(a) Tax filer EDG:

(A) For individuals who intend to file a federal income tax return, who are not claimed as a tax dependent by another individual, the EDG consists of:

(i) The tax filer;

(ii) The tax filer’s spouse, with the following considerations:

(I) If living together, the tax filer’s spouse is included in the EDG of the tax filer, irrespective of the spouse’s tax filing status; and

(II) If living separately, the tax filer’s spouse is included in the EDG of tax filer if they intend to claim a tax filing status of Married Filing Jointly.

(iii) All individuals whom the tax filer intends to claim as tax dependents.

(B) For tax filers who expect to be claimed as a tax dependent by another individual, the EDG is determined in accordance with section (1)(b) of this rule.

(b) Tax dependent EDG:

(A) Except as described in subsection (B) of this part (1)(b)(B), the EDG of an individual who expects to be claimed as a tax dependent is the same as the EDG of the tax filer who intends to claim them, as outlined in section (1) of this rule.

(B) For tax dependents who meet any of the following exceptions, the EDG is determined in accordance with section (3) of this rule:

(i) The individual is claimed as a tax dependent by someone other than a parent or spouse;

(ii) The individual is a child living with both parents but is claimed as a tax dependent by one parent; or

(iii) The individual is a child living with a parent and is claimed as a tax dependent by a non-custodial parent.

(A) An individual’s EDG is determined in accordance with this section if:

(i) The individual does not expect to file a tax return and is not claimed as a tax dependent;

(ii) The individual does not expect to file a tax return and cannot substantiate whether or not they shall be included in the tax return of another individual; or

(iii) The individual expects to be claimed as a tax dependent and meets an exception described in section (1)(b) of this rule.

(B) The non-filer EDG consists of the following individuals, if living in the same household:

(i) The individual;

(ii) The individual’s spouse;

(iii) The individual’s children; and

(iv) If the individual is a child, their parents and child siblings;

(2) When establishing eligibility for OHP Bridge - Basic Health Program, each individual shall have their own Eligibility Determination Group (EDG) determined individually based on the following EDG rules:

(a) Tax filer EDG:

(A) For individuals who intend to file a federal income tax return, who are not claimed as a tax dependent by another individual, the EDG consists of:

(i) The tax filer;

(ii) The tax filer’s spouse, if they intend to claim Married Filing Jointly; and

(iii) All individuals whom the tax filer intends to claim as tax dependents.

(B) For tax filers who expect to be claimed as a tax dependent by another individual, the EDG is determined in accordance with subsection (b) of this section (2)(b).

(b) Tax dependent EDG:

(A) The EDG of an individual who is claimed as a tax dependent by a tax-filer with whom they live consists of all individuals included in the tax-filer’s EDG.

(B) The EDG of an individual who is claimed as a tax dependent by someone with whom they do not live is based on non-filer EDG criteria outlined in subsection (c) of this part.

(A) An individual’s EDG is determined in accordance with this section if:

(i) The individual does not expect to file a tax return and is not claimed as a tax dependent;

(ii) The individual does not expect to file a tax return and cannot substantiate whether or not they shall be included in the tax return of another individual;

(iii) The individual expects to be claimed as a tax dependent by someone outside of their home, as referenced in section (2)(b)(B) of this part; or

(iv) The Individual expects to file their tax return using a status of Married Filing Separately.

(B) The non-filer EDG consists of the following individuals, if living in the same household:

(i) The individual;

(ii) The individual’s spouse;

(iii) The individual’s children; and

(iv) If the individual is a child, their parents and child siblings;

(3) Individuals described in this rule are still considered EDG members if they are temporarily absent from the household with intent to return to the household when the purpose of their absence is complete. Reasons for temporary absence include but are not limited to:

(a) Education;

(b) Military;

(d) Incarceration; or

(e) Hospitalization.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 414.447 & 414.706
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0310 Eligibility and Budgeting; Health Systems Division Medical Programs.

(1) Eligibility is evaluated by reviewing the financial and non-financial information for the applicable budget months. The budget month is established as follows.

(a) For new applicants, the budget month is:

(A) The initial budget month is the month in which the Date of Request (DOR) is established; or

(B) If ineligible in the initial budget month, the agency shall evaluate eligibility for the subsequent month.

(b) For retroactive medical, the budget month is the month in which the applicant received medical services for which they are requesting payment.

(A) At renewal, the month in which a renewal response is received by the agency;

(B) The month a change that affects eligibility is reported; or

(2) MAGI and MAGI-based income not specifically excluded is countable, and its value is used in determining the eligibility and benefit level of an applicant or beneficiary.

(3) MAGI and MAGI-based income is considered available on the date it is received or the date a member of the EDG has a legal right to the payment and the legal ability to make it available, whichever is earlier, except as follows:

(a) Income usually paid monthly or on some other regular payment schedule is considered available on the regular payment date if the date of payment is changed because of a holiday or weekend;

(b) Income withheld or diverted at the request of an individual is considered available on the date the income may have been paid without the withholding or diversion;

(4) For all HSD Medical Programs except OHP Bridge – Basic Health Program, financial eligibility is evaluated for the initial budget month by comparing the combined total of each EDG member’s countable MAGI-based income to the income standards for the appropriate family size. Countable MAGI-based income is determined as follows:

(a) For EDG members with ongoing income (the income has not started, changed, or ended in the month being evaluated), the agency shall evaluate eligibility based on converted income. Converted income is calculated by considering the average amount of representative income received per pay period, then converting to a monthly amount using the following conversion standards:

(A) Average weekly income is multiplied by 4.3;

(B) Average bi-weekly income is multiplied by 2.15;

(D) For ongoing income received less frequently than monthly (i.e. quarterly), the payment amount shall be divided by the appropriate number of months to arrive at a monthly average.

(b) For EDG members whose income started or ended in a month being evaluated for eligibility, or changed such that income prior to the month being evaluated is not representative of current or future months:

(A) For income expected to be received monthly or more frequently, the agency shall evaluate initial budget month eligibility by combining the actual income received and expected to be received in the budget month. Income is then converted to an ongoing amount using the methodology described in subsection (4)(a) of this part for ongoing eligibility.

(B) For income expected to be paid on a regular basis less often than monthly, income is converted as described in subsection (4)(a)(D) of this part for budget month and ongoing eligibility.

(5) If ineligible under section (4) because the MAGI-based income is over the applicable HSD Medical Program income standard based on family size, MAGI income shall be annualized using the requirements of 26 CFR §1.36 B-1(e) for the calendar year in which medical has been requested.

(a) For all MAGI Medicaid/CHIP programs, if the annual income is at or below 100 percent FPL), income shall be divided by 12 to derive a monthly amount and applied to the budget month for initial and ongoing eligibility.

(b) For OHP Bridge – Basic Health Program , if the annual income is between 133 and 200 percent FPL, that amount shall be used in the eligibility determination.

(6) If ineligible under sections (4) or (5) of this rule, the agency shall evaluate eligibility for the subsequent month using the methodology described in section (4) of this rule. If eligible, the effective date of eligibility is established as described in HSD Medical Programs – Effective Dates (OAR 410-200-0115).

(7) Financial eligibility for retroactive months (see OAR 410-200-0130) is first evaluated in accordance with section (4) of this rule. If a conversion of ongoing income results in ineligibility, the agency shall consider the actual countable income received in the retroactive month. If eligible, the effective date of eligibility is established as described in HSD Medical Programs – Effective dates (OAR 410-200-0115).

(8) In the following scenarios, an individual’s countable income may be reduced by an amount equivalent to five percentage points of the FPL based on the applicable family size:

(a) A child who is ineligible for MAGI Medicaid programs (MAGI Child (OAR 410-200-0415), MAGI Parent or Caretake Relative (OAR 410-200-0420), MAGI Pregnant Woman (OAR 410-200-0425)) and may otherwise be eligible for MAGI CHIP (OAR 410-200-0410); if the countable income reduced by five percentage points of the FPL is within the income standard for a MAGI Medicaid program, the individual meets the financial eligibility for that program.

(b) Allowable Reduction of Countable Income for all HSD Medical Programs, except OHP Bridge – Basic Health Program. If the countable income, when it is reduced by five percentage points of the FPL, is within the income standard for any HSD Medical Program, then the individual meets the financial eligibility requirements for that program. However, the five percentage point reduction is not used to determine financial eligibility for OHP Bridge – Basic Health Program.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 414.447 & 414.706
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 25-2020, amend filed 05/08/2020, effective 05/08/2020
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0315 Standards and Determining Income Eligibility

(1) This rule outlines income thresholds for Health System Division (HSD) Medical Programs. See OAR 410-200-0310 for eligibility and budgeting.

(2) The income standard for the Modified Adjusted Gross Income (MAGI) Parent or Caretaker-Relative program is set as follows: See attached table.

(3) Effective March 1, 2026, the income standard for the MAGI Child Program and the MAGI Adult Program is set at 133 percent of the 2026 Federal Poverty Level (FPL) as follows: See attached table.

(4) Effective March 1, 2026, the income standard for the MAGI Pregnant Woman Program and for MAGI Child Program recipients under the age of one year is set at 185 percent of the 2026 FPL as follows: See attached table.

(5) Effective March 1, 2026, the income standard for MAGI Children’s Health Insurance Program (CHIP) is set at 300 percent of the 2026 FPL as follows: See attached table.

(6) Effective July 1, 2026, the income standard for OHP Bridge - Basic Health Program and OHP Bridge – Basic Medicaid is set at 200 percent of the 2026 Federal Poverty Level (FPL) as follows: See attached table.

(7) Effective March 1, 2026, the income standard for the Compact of Free Association (COFA) Dental Program is set at 133 percent of the 2026 FPL as follows: See attached table.

(8) Effective March 1, 2026, the income standard for the Veteran Dental Program is set at 400 percent of the 2026 FPL as follows: See attached table.

(9) Effective March 1, 2026, the income standard for the Young Adults with Special Health Care Needs Program is set at 200 percent of the 2026 FPL as follows: See attached table.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: 42 CFR 435.110, ORS 435.112, 435.115, 435.116, 435.118, 435.403, 435.940, 42 CFR 435.1200, 457.80, 457.340, 458.350, 435.3, 435.4, 435.406, 435.407, 435.940, 435.952, 435.956, 435.1008, 457.320, 457.380, 435.608, 433.138, 433.145, 433.146, 433.147, 433.148, 435.117, 435.119, 42 CFR 435.1200, 42 CFR 435.1205, 435.170, 435.190, 435.222, 435.610, 435.916, 435.917, 447.56, 457.350, 457.360, 457.805, ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.402, 411.404, ORS 411.060, 411.095, 411.400, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.440, 414.534, 414.536 & 414.706
DMAP 7-2026, amend filed 02/26/2026, effective 03/01/2026
DMAP 67-2025, amend filed 09/10/2025, effective 09/18/2025
DMAP 30-2025, temporary amend filed 03/10/2025, effective 03/10/2025 through 09/05/2025
DMAP 29-2025, amend filed 02/26/2025, effective 03/01/2025
DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 78-2024, temporary amend filed 03/15/2024, effective 03/15/2024 through 08/13/2024
DMAP 43-2024, temporary amend filed 02/16/2024, effective 03/01/2024 through 08/13/2024
DMAP 11-2023, amend filed 03/30/2023, effective 04/01/2023
DMAP 6-2023, amend filed 02/23/2023, effective 03/01/2023
DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023
DMAP 73-2022, amend filed 09/07/2022, effective 09/07/2022
DMAP 35-2022, temporary amend filed 02/18/2022, effective 03/01/2022 through 08/27/2022
DMAP 34-2021, amend filed 08/24/2021, effective 08/24/2021
DMAP 7-2021, temporary amend filed 02/23/2021, effective 03/01/2021 through 08/27/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 5-2020, temporary amend filed 02/25/2020, effective 03/01/2020 through 08/27/2020
DMAP 34-2019, amend filed 08/23/2019, effective 08/27/2019
DMAP 1-2019, temporary amend filed 02/28/2019, effective 03/01/2019 through 08/27/2019
DMAP 21-2018, amend filed 04/12/2018, effective 04/12/2018
DMAP 10-2018, temporary amend filed 02/14/2018, effective 02/14/2018 through 08/12/2018
DMAP 15-2017, f. 4-28-17, cert. ef. 5-1-17
DMAP 6-2017(Temp), f. 2-28-17, cert. ef. 3-1-17 thru 8-27-17
DMAP 22-2016, f. & cert. ef. 5-18-16
DMAP 12-2016(Temp), f. 2-25-16, cert. ef. 3-1-16 thru 8-27-16
DMAP 27-2015, f. 4-21-15, cert. ef. 4-22-15
DMAP 6-2015(Temp), f. 2-13-15, cert. ef. 3-1-15 thru 8-27-15
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 53-2014, f. & cert. ef. 9-23-14
DMAP 25-2014(Temp), f. & cert. ef. 4-14-14 thru 10-11-14
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0400 Specific Requirements; Breast and Cervical Cancer Treatment Program (BCCTP)

This rule establishes eligibility criteria for medical assistance based on an individual's need of treatment for breast or cervical cancer, including pre-cancerous conditions (treatment). The Authority administers the Oregon Breast and Cervical Cancer Treatment Program (BCCTP) by entering into agreements with qualified entities as approved by the Authority to provide screening services for BCCTP funded by the Centers for Disease Control in support of the National Breast and Cervical Cancer Early Detection Program.

(1) To be eligible for BCCTP, an individual must:

(a) Be found to need treatment following screening services provided by a qualified entity;

(b) Be under the age of 65;

(d) Not be receiving Medicaid through a Medicaid program listed in 42 U.S.C. §1396a(a)(10)(A)(i) (mandatory Medicaid eligibility groups).

(2) An individual is presumptively eligible for BCCTP beginning the day a qualified entity determines, on the basis of preliminary information, that they are likely to meet the requirements of section (1). A qualified entity that determines an individual presumptively eligible for BCCTP shall:

(a) Notify the Authority of the determination within five working days; and

(b) Explain to the individual at the time the determination is made the circumstances under which an application for medical assistance shall be submitted to the Authority and the deadline for the application (see section (3)).

(3) To remain eligible for benefits, an individual determined by a qualified entity to be presumptively eligible for BCCTP shall apply for medical assistance no later than the last day of the month following the month in which the determination of presumptive eligibility is made. Presumptive eligibility for BCCTP ends on:

(a) The last day of the month following the month in which presumptive eligibility begins, if the individual does not file an application by that date;

(b) The day on which a determination is made for other Medicaid/CHIP program benefits.

(4) An individual found eligible for the BCCTP by the Authority becomes ineligible at the point at which any of the following occur:

(a) The treating health professional determines the course of treatment is complete;

(b) Upon reaching age 65;

(d) Upon becoming a resident of another state;

(e) When the Authority determines they do not meet the requirements for eligibility.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536, 414.540 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0405 Specific Requirements; Substitute Care

In addition to eligibility requirements applicable to the Substitute Care program in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the Substitute Care program, effective 10/01/13.

(1) To be eligible for Substitute Care, an individual shall be under the age of 21 and live in a Behavioral Rehabilitation Services (BRS) facility or an intermediate Psychiatric Residential Treatment Facility (PRTF) for which a public agency of Oregon is assuming at least partial financial responsibility, including those placed in an intermediate psychiatric care facility by the Oregon Youth Authority.

(2) While living in an intermediate psychiatric care facility, an individual’s EDG consists of the individual only.

(3) There is no income test for Substitute Care.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 413.032, 413.038, 414.025, 414.231 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0407 Specific Requirements; Former Foster Care Youth Medical Program

This rule describes specific eligibility requirements for the Former Foster Care Youth Program (FFCYM).

(1) There is no income test for the FFCYM Program.

(2) An individual is eligible for the FFCYM Program if the individual meets the requirements of all of the following:

(a) Is at least age 18 and under age 26;

(b) Was in foster care under the responsibility of any state or a Tribe within that state and was enrolled in Medicaid under the State's Medicaid State plan or under a section 1115 demonstration project upon attaining:

(A) Age 18; or

(B) If over 18, the age at which that state’s or Tribe within that state’s foster care assistance ended under Title IV-E of the Act.

(d) Is not receiving adoption assistance or foster care maintenance payments.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534
Statutes/Other Implemented: ORS 411.060, 411.095, 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 411.447, 413.032, 413.038, 414.025, 414.231, 414.534, 414.536 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 23-2016, f. & cert. ef. 6-2-16
DMAP 73-2015(Temp), f. & cert. ef. 12-18-15 thru 6-14-16

Or. Admin. R. 410-200-0410 Specific Requirements; MAGI CHIP

In addition to eligibility requirements applicable to MAGI CHIP in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the MAGI CHIP program.

(1) Individuals may not be eligible for MAGI CHIP with an effective date prior to October 1, 2013.

(2) To be eligible for MAGI CHIP, an individual must:

(a) Be under 19 years of age; and

(b) Meet the budgeting requirements of OAR 410-200-0315.

(3) To be eligible for MAGI CHIP, an individual may not:

(a) Be eligible for MAGI Child, MAGI Pregnant Woman, MAGI Parent or Caretaker Relative, or Substitute Care programs;

(b) Be receiving or deemed to be receiving SSI benefits; and

(c) Be covered by minimum essential coverage. For the purposes of this rule, a child is not considered to have minimum essential coverage if it is not accessible for one or more of the following reasons:

(A) The travel time or distance to available providers within the minimum essential coverage network exceeds:

(i) In urban areas: 30 miles, 30 minutes, or the community standard, whichever is greater; or

(ii) In rural areas: 60 miles, 60 minutes, or the community standard, whichever is greater;

(B) Accessing the minimum essential coverage would place a member of the household at risk of harm.

(4) For the Authority to enroll a child in MAGI CHIP based on a determination made by an Express Lane Agency (ELA), the child’s parent or guardian shall give consent in writing, by telephone, orally, or through electronic signature.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 413.032, 413.038, 414.025, 414.231 & 414.706
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0415 Specific Requirements; MAGI Child

In addition to eligibility requirements applicable to the MAGI Child program in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the MAGI Child program.

(1) To be eligible for the MAGI Child program, the child must:

(a) Be under the age of 19; and

(b) With the exception of section (3) below, have household income at or below:

(A) 133 percent of the federal poverty level (OAR 410-200-0315) for the applicable family size for a child over the age of one but less than age 19; or

(B) 185 percent of the federal poverty level for the applicable family size for an infant under the age of one.

(2) A child born to an individual who is eligible for and receiving Medicaid/CHIP benefits is an Assumed Eligible Newborn (AEN) for the MAGI Child program until the end of the month in which the child turns one year of age (see OAR 410-200-0135). There is no income limit for an AEN.

(3) To be eligible for the MAGI Child Program, an individual may not:

(a) Be receiving or deemed to be receiving SSI benefits;

(b) Be eligible for Substitute Adoptive Care, MAGI Parent and Caretaker Relative, or MAGI Pregnant Woman programs.

(4) To enroll a child in the MAGI Child program based on a determination made by an Express Lane Agency (ELA), the child's parent or guardian shall give consent in writing, by telephone, orally, or through electronic signature.

(5) ELE qualifies a child for medical assistance benefits based on a finding from the Department, even when the Department’s eligibility methodology differs from that used for HSD Medical Programs.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447 & 414.706
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15; ; DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16

Or. Admin. R. 410-200-0420 Specific Requirements; MAGI Parent or Caretaker Relative

In addition to eligibility requirements applicable to the MAGI Parent or Caretaker Relative program in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the MAGI Parent or Caretaker Relative program.

(1) To be eligible for the MAGI Parent or Caretaker Relative program, an individual must meet the criteria outlined in section (2) or (3) of this rule.

(2) An individual is eligible for the MAGI Parent or Caretaker Relative Program if they meet the financial and non-financial eligibility requirements as follows:

(a) Is a parent, caretaker relative, or spouse of the parent or caretaker relative who assumes primary responsibility for a dependent child living in the home; and

(b) Has EDG income at or below the income standard for the applicable family size as identified in OAR 410-200-0315.

(3) An individual is eligible for the MAGI Parent or Caretaker Relative program if they are entitled to a period of Continuous Eligibility OAR 410-200-0240(2) and do not meet the financial and non-financial eligibility requirements for any Health System Division (HSD) medical or OSIPM program OAR 461-135-0010 subject to Continuous Eligibility of the same benefit level.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 414.447 & 414.706
DMAP 40-2024, amend filed 02/01/2024, effective 02/01/2024
DMAP 57-2023, temporary amend filed 07/17/2023, effective 07/18/2023 through 01/12/2024
DMAP 56-2023, temporary amend filed 07/17/2023, effective 07/17/2023 through 07/17/2023
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0425 Specific Requirements; MAGI Pregnant Woman

In addition to eligibility requirements applicable to the MAGI Pregnant Woman program in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the MAGI Pregnant Woman program.

(1) To be eligible for the MAGI Pregnant Woman program, an individual must be pregnant at least one day in the month for which eligibility is being determined, including months they are being evaluated for Retroactive Medical (OAR 410-200-0130).

(2) To be eligible for the MAGI Pregnant Woman program, an individual must:

(a) Have household income that is at or below 185 percent of the federal poverty level (OAR 410-200-0315); or

(b) Be eligible for protected eligibility according to the policy described in OAR 410-200-0135.

(3) To be eligible for the MAGI Pregnant Woman program, an individual must not be receiving Supplemental Security Income (SSI).

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 414.447 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0435 Specific Requirements; MAGI Adult

In addition to eligibility requirements applicable to the MAGI Adult program in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the MAGI Adult program.

(1) To be eligible for the MAGI Adult program an individual must:

(a) Be 19 years of age or older and under age 65; and

(b) Have household income at or below 133 percent federal poverty level (OAR 410-200-0315) for the applicable family size.

(2) To be eligible for the MAGI Adult program, an individual may not be:

(a) Pregnant;

(b) Entitled to or enrolled for Medicare benefits under part A or B of Title XVIII of the Act;

(d) A parent or caretaker relative of a child living in the home who is not enrolled in minimum essential coverage.

History

Statutory/Other Authority: ORS 411.402, 411.404 & 413.042
Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447 & 414.706
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0437 Specific Requirements: OHP Bridge - Basic Medicaid.

In addition to the general eligibility requirements applicable to OHP Bridge - Basic Medicaid as set out in OAR Chapter 410, Division 200, this rule describes specific eligibility requirements for OHP Bridge - Basic Medicaid.

(1) OHP Bridge - Basic Medicaid is effective on July 1, 2024.

(2) To be eligible for OHP Bridge - Basic Medicaid an individual must:

(a) Be age 19 or older and under age 65;

(b) Have, as required under OAR 410-200-0315, monthly MAGI-based household income greater than 133 percent of the federal poverty level (FPL) up to and including 200 percent federal poverty level for the applicable family size;

(c) Meet citizenship requirements outlined in OAR 410-200-0215 (1) or non-citizen status requirements outlined in OAR 410-200-0215 (4);

(d) Be exempt from mandatory enrollment in a non-Indian Managed Care Entity based on American Indian or Alaska Native status as is specified in section 1932 (2)(C) of the Social Security Act and its implementing federal regulation, 42 CFR 438.50 (d)(2).

(3) Even if an individual meets the requirements in section (2) above of this rule, the individual shall not be eligible for OHP Bridge - Basic Medicaid if they:

(a) Are enrolled in Medicare benefits under part A or B of Title XVIII of the Act; or

(b) Are receiving other healthcare coverage that qualifies as Minimum Essential Coverage as defined in OAR 410-200-0015 (55), unless that coverage is an Insurance Affordability Program as defined in OAR 410-200-0015 (50); or

(c) Be able to access affordable coverage as described in section 36B(c)(2)(C)(i)(II) and § 1.36B–2(c)(3)(v)(A)( 1 ) of the IRS Code. The required contribution percentage is indexed annually under section 36B(c)(2)(C)(iv); or

(d) Are receiving Supplemental Security Income (SSI) benefits.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 414.241, 414.534, 42 CFR 433.138, 433.145-433.148, 435.3-435.4, 435.110, 435.115-435.119, 435.170, 435.190, 435.222, 435.403, 435.406-435.407, 435.608, 435.610, 435.916-435.917, 435.940, 435.952, 435.956, 435.1008, 435.1200, 435.1205, 447.56, 457.80, 457.320, 457.340, 457.350, 457.360, 457.380, 457.805, 458.350 & 435.112
Statutes/Other Implemented: ORS 411.402, 411.404, 414.534, ORS 411.060, 411.095, 411.400, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.241, 414.440, 414.534, 414.536 & 414.706
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-200-0438 Specific Requirements: OHP Bridge – Basic Health Program

In addition to the general requirements applicable to OHP Bridge – Basic Health Program set forth in this Division 200, this rule describes specific eligibility requirements for OHP Bridge – Basic Health Program.

(1) OHP Bridge – Basic Health Program is effective on July 1, 2024.

(2) To be eligible for OHP Bridge – Basic Health Program an individual must:

(a) Be age 19 or older and under age 65;

(b) Have, as required under OAR 410-200-0315, monthly MAGI-based income which exceeds 133 percent of the federal poverty level (FPL) for the applicable family size; have annual household income for the applicable family size between 133 percent and up to and including 200 percent FPL for the coverage year being requested; and

(c) Meet citizenship status requirements outlined in OAR 410-200-0215(1), or non-citizen status requirements outlined in OAR 410-200-0215(5).

(3) Even if an individual meets the requirements in section (2) of this rule, the individual shall not be eligible for OHP Bridge – Basic Health Program if they:

(a) Are enrolled in Medicare benefits under part A or B of Title XVIII of the Act; or

(b) Are receiving other healthcare coverage that qualifies as Minimum Essential Coverage as defined in OAR 410-200-0015(55), unless that coverage is an Insurance Affordability Program as defined in OAR 410-200-0015(50); or

(c) Are able to access affordable coverage as described in section 36B(c)(2)(C)(i)(II) of the IRS Code and 26 CFR section 1.36B–2(c)(3)(v)(A)(1). The required contribution percentage is indexed annually under section 26 U.S.C. 36B(c)(2)(C)(iv); or

(d) Are receiving Supplemental Security Income (SSI) benefits.

(4) OHP Bridge – Basic Health Program eligibility is re-evaluated every twelve (12) months.

(5) An individual who is approved for OHP Bridge – Basic Health Program coverage is entitled to twelve (12) months of coverage provided they continue to meet non-financial eligibility criteria. Once approved, an individual’s OHP Bridge – Basic Health Program coverage shall not be terminated during a twelve (12) month eligibility period due to an increase of countable income.

History

Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 414.241, 414.534, 42 CFR 433.138, 433.145-433.148, 435.3-435.4, 435.110, 435.115-435.119, 435.190, 435.222, 435.403, 435.406-435.407, 435.608, 435.610, 435.916-435.917, 435.940, 435.952, 435.956, 435.1008, 435.1200, 435.1205, 447.56, 457.80, 457.320, 457.340, 457.350, 457.360, 457.380, 457.805, 458.350, 435.112, 435.170 & 42 CFR 600
Statutes/Other Implemented: ORS 411.402, 411.404, 414.241, ORS 411.060, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.440, 414.534, 414.536, 414.706, 411.095 & 411.400
DMAP 85-2025, amend filed 12/02/2025, effective 12/02/2025
DMAP 49-2025, temporary amend filed 06/10/2025, effective 06/10/2025 through 12/06/2025
DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024

Or. Admin. R. 410-200-0440 Specific Requirements; Extended Medical Assistance

In addition to eligibility requirements applicable to Extended Medical Assistance (EXT) in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the EXT program.

(1) Except for individuals receiving MAGI Parent or Caretaker Relative (PCR) due to Continuous Eligibility (OAR 410-200-0420(3), individuals who lose eligibility for MAGI PCR for the receipt or increase of earned income are eligible for a period of twelve months of Extended Medical Assistance (EXT) if they were eligible for and receiving MAGI PCR benefit for any one of the six months preceding the receipt or increase in earned income that resulted in the loss of MAGI PCR eligibility

(2) Except for those receiving benefits under OAR 410-200-0420(3), individuals who lose eligibility for MAGI PCR due to the receipt or increase of spousal support are eligible for a period of four months of EXT if they were eligible for and receiving MAGI PCR benefits for any three of the six months preceding the receipt or increase in spousal support that resulted in the loss of MAGI PCR eligibility

(3) The dependent children of individuals described in sections (1) and (2) are eligible for EXT for the same time period as their parent or caretaker relative if:

(a) They lost Medicaid eligibility due to the parent or caretaker relative’s receipt or increase of earned income or spousal support; and

(b) Eligibility is redetermined and they are not eligible for any Medicaid program.

(4) The EXT eligibility period as described in sections (1) and (2) above is established as follows:

(a) If the determination is made on or before the 15th of the month, the EXT eligibility period will begin the first of the following month.

(b) If the determination is made on or after the 16th of the month, the EXT eligibility period will begin the first of the month following the next month.

(5) Individuals are not eligible for EXT if there is not a parent or caretaker relative and dependent child living in the home.

(6) Individuals described in sections (1) through (3) of this rule who lose EXT eligibility for one of the following reasons may regain EXT eligibility for the remainder of the original EXT eligibility period if:

(a) EXT eligibility was lost because the individual left the household during the EXT eligibility period. The individual may regain EXT eligibility if they return to the household; or

(b) EXT eligibility was lost due to a change in circumstance that resulted in eligibility for another Medicaid program, and then a subsequent change in circumstance occurred that resulted in loss of eligibility for all Medicaid Programs.

(7) Individuals who lose eligibility for MAGI PCR and would be eligible to receive EXT except that they are determined eligible for another Medicaid program, and their dependent children, shall receive EXT benefits for the remainder of their original EXT eligibility period if:

(a) They subsequently lose eligibility for all Medicaid programs; and

(b) They continue to meet the non-financial eligibility requirements of MAGI PCR.

History

Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038 & 414.025
Statutes/Other Implemented: ORS 411.095, 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 411.447 & 414.706
DMAP 60-2025, amend filed 08/08/2025, effective 08/15/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 53-2015, f. 9-22-15, cert. ef. 9-25-15
DMAP 31-2015(Temp), f. & cert. ef 6-16-15 thru 9-28-15
DMAP 19-2015(Temp), f. & cert. ef. 4-2-15 thru 9-28-15
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14

Or. Admin. R. 410-200-0445 Specific Requirements – Compact Of Free Association (COFA) Dental Program

(1) The Compact of Free Association (COFA) Dental Program is effective January 1, 2023.

(2) To be eligible for the COFA Dental Program, an individual must:

(a) Be lawfully residing in the United States in accordance with the Compacts of Free Association (I.e., the governments of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau);

(b) Be a resident of Oregon; and

(3) To be eligible for the COFA Dental Program, an individual must not be eligible for Medicaid under Title XIX of the Social Security Act or the Children’s Health Insurance Program under Title XXI of the Social Security Act.

(4) The begin-date of COFA Dental Program benefits will align with OAR 410-200-0115 HSD Medical Programs – Effective Dates.

(5) The Agency shall accept self-attestation of the eligibility requirements described in this rule, unless questionable.

History

Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038, 414.025 & 414.534
Statutes/Other Implemented: ORS 411.095, 411.402, 411.404, 413.038, 414.025, 411.400, 411.406, 411.439, 413.032, 414.231, 414.536 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 89-2022, adopt filed 12/16/2022, effective 01/01/2023

Or. Admin. R. 410-200-0450 Specific Requirements – Veteran Dental Program

(1) The Veteran Dental Program is effective January 1, 2023.

(2) To be eligible for the Veteran Dental Program, an individual must:

(a) Be a resident of Oregon;

(b) Be a veteran as described in ORS 408.225, except the individual may be discharged or released under honorable conditions or other conditions; and

(3) Individuals found eligible for the Veteran Dental Program must provide verification of discharge as a condition of ongoing eligibility.

(4) To be eligible for the Veteran Dental program an individual must not be eligible for Medicaid under Title XIX of the Social Security Act or the Children’s Health Insurance Program under Title XXI of the Social Security Act, except an individual may be eligible for and receive Medicare Savings Programs.

(5) The begin-date of Veteran Dental Program benefits will align with OAR 410-200-0115 HSD Medical Programs – Effective Dates.

(6) Eligibility for Veteran Dental Program is subject to the availability of funds. The agency may close enrollment and implement the Veteran Dental Program reservation list when enrollment has reached capacity. The reservation list will retain the information of individuals who would have been found eligible for the Veteran Dental Program if not for closed enrollment.

(a) Individuals who apply and are denied the Veteran Dental Program due solely to closed enrollment will be added to the reservation list in date-order, based on the Date of Request (DOR) of the application that was denied.

(b) When enrollment is reopened, individuals will be selected from the reservation list in oldest to newest DOR date order. Once selected, the agency shall:

(A) Initiate a DOR on the individual’s behalf;

(B) Send notification to inform the individual that they’ve been selected from the reservation list;

(c) Failure to reapply within the timeframe provided will result in inactivation of their reservation. Individuals may reapply at any time.

History

Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038 & 414.025
Statutes/Other Implemented: ORS 411.095, 411.402, 411.404, 413.038, 414.025, 414.534, 411.400, 411.406, 411.439, 413.032, 414.231, 414.536 & 414.706
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 89-2022, adopt filed 12/16/2022, effective 01/01/2023

Or. Admin. R. 410-200-0455 Specific Requirements - Young Adults with Special Health Care Needs

In addition to the other eligibility requirements applicable to the Young Adults with Special Health Care Needs (YSHCN) program as set forth elsewhere within Chapter 410, including Division 200, this rule describes the specific eligibility requirements for the YSHCN program.

(1) The YSHCN program provides OHP Plus coverage and supplementary benefits for individuals who meet the eligibility criteria, as follows:

(a) For individuals who are not eligible for an OHP Plus-level HSD Medical program under OAR 410-200-0015(47)(d) or 410-200-0015(47)(f)(A)-(E) or Oregon Supplemental Income Program Medical (OSIPM) program under OAR 461-101-0010(18), YSHCN provides full OHP Plus coverage as described in OAR 410-120-1210(4)(g)(A) as well as supplemental benefits described in OAR 410-120-1210(4)(g)(A)-(C).

(b) For individuals who are eligible for an OHP Plus-level HSD Medical program under OAR 410-200-0015(47)(d) or 410-200-0015(47)(f)(A)-(E) or OSIPM program under OAR 461-101-0010(18), YSHCN provides supplemental benefits described in OAR 410-120-1210(4)(g)(A)-(C).

(2) To be eligible for the YSHCN program, an individual must meet the following criteria:

(a) Meet the age requirement:

(A) For dates of request or redeterminations during the 2025 calendar year:

(i) Be 19 or 20 years of age in the month of their date of request or redetermination; or

(ii) Be eligible for and receiving YSHCN coverage at the time they turn 21 years of age.

(B) For dates of request or redeterminations during the 2026 calendar year:

(i) Be 19, 20 or 21 years of age in the month of their date of request or redetermination; or

(ii) Be eligible for and receiving YSHCN coverage at the time they turn 22 years of age.

(b) Meet the financial requirement:

(A) Be eligible for a MAGI Medicaid/CHIP program as defined in OAR 410-200-0015(47)(d) or 410-200-0015(47)(f)(A)-(E) or an OSIPM program as defined in OAR 461-101-0010(18); or

(B) Have MAGI-based household income under 200 percent (200%) of the federal poverty level (OAR 410-200-0315) for the applicable family size.

(A) Be identified as having a "complex chronic" condition or conditions based on the Pediatric Medical Complexity Algorithm (PMCA), which is found at the following URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035595/;

(B) Have a serious emotional disturbance or serious mental health issue as defined by an OHA-approved list of behavioral health diagnoses;

(C) Be eligible for services due to an intellectual or developmental disability, as described in OAR 411-320-0080, on or after turning 16 years of age; or

(D) Meet at least two (2) of the six (6) categories represented in the YSHCN eligibility screening questions as follows:

(i) Receives or requires prescription medication for a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19;

(ii) Often uses or often needs medical care, mental health, or other health services for a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19;

(iii) Needs assistance to perform everyday activities due to a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19;

(iv) Receives or needs treatment or counseling for a mental health, substance use, or emotional condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19;

(v) Often uses or often needs medical therapies, excluding counseling or talk therapy, for a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19; or

(vi) Often uses or often needs medical equipment or assistive devices due to a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19.

(3) The health-related qualifications for YSHCN non-financial eligibility described in section (2)(c) of this rule shall be reassessed as described below based on the method by which eligibility was initially determined as follows:

(a) For YSHCN beneficiaries who were determined eligible based on the Pediatric Medical Complexity Algorithm (PMCA) described in section (2)(c)(A) of this rule, at each renewal, the Agency shall review submitted claims to confirm whether the individual has continued to receive care for the qualifying condition within the prior three (3) years. The Agency will:

(A) Continue YSHCN eligibility for the individual after confirming that the individual has sought care or services for their qualifying condition within the prior three (3) years, and as long as all other eligibility conditions are met; or

(B) Disenroll the individual from YSHCN after confirming that the individual has not sought care or services for their qualifying condition within the prior three (3) years.

(b) For YSHCN beneficiaries who were determined eligible based on a qualifying behavioral health diagnosis as described in sections (2)(c)(B) of this rule, at renewal, the Agency shall review submitted claims to confirm whether the individual has continued to receive care for the qualifying condition within the prior two (2) years. The Agency shall:

(A) Continue YSHCN eligibility for the individual after confirming that the individual has sought care or services for their qualifying condition within the prior two (2) years, and as long as all other eligibility conditions are met; or

(B) Disenroll the individual from YSHCN after confirming that the individual has not sought care or services for their qualifying condition within the prior two (2) years.

(c) For YSHCN beneficiaries who were determined eligible based on the YSHCN eligibility screening questions described in section (2)(c)(D), the screening must be performed at least every two (2) years at renewal. If the individual meets at least two (2) of the six (6) categories represented in the screening, this requirement is considered met when eligibility is evaluated.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719, 414.632, 411.402, 411.404, 411.095, 411.400, 411.406, 413.032, 413.038 & 414.706
DMAP 81-2025, amend filed 11/17/2025, effective 01/01/2026
DMAP 138-2024, adopt filed 11/26/2024, effective 01/01/2025

Or. Admin. R. 410-200-0521 Unwinding Period - HSD Medical Programs

(1) The provisions in this rule apply to all Health Systems Division (HSD) Medical Program determinations effective April 1, 2023, through February 28, 2025. Notwithstanding any other rule to the contrary in these chapter 410 division 200 rules, during the unwinding period, HSD Medical Program eligibility shall be determined as set forth in this rule.

(2) For the purposes of this rule, the term “unwinding period” refers to the period of April 1, 2023 through February 28, 2025 in which the agency will initiate a full eligibility renewal for all HSD Medical Program beneficiaries.

(3) In accordance with the Consolidated Appropriations Act, 2023, the continuous enrollment conditions established via the Families First Coronavirus Response Act end effective March 31, 2023.

(4) Except for individuals receiving coverage during a period of presumptive eligibility (see OAR 410-200-0105), individuals who were receiving HSD Medical Program benefits prior to April 1, 2023, shall maintain coverage as described in OAR 410-200-0520 until their unwinding period renewal activity is initiated.

(5) Individuals receiving coverage during a period of presumptive eligibility shall maintain presumptive eligibility coverage until:

(a) A full eligibility determination is completed; or

(b) The individual’s benefits are terminated due to failure to complete the full application process.

(6) The Agency shall determine eligibility based on self-attestation of financial eligibility information and will request necessary verification (see OAR 410-200-0230 – Verification) via post-eligibility Request for Information (RFI).

(7) Information about RFIs during the unwinding period:

(a) The Agency will provide 90-days to respond to RFIs;

(b) Failure to respond to a post-eligibility RFI will result in termination of benefits in accordance with section (8) of this rule, with the following exceptions:

(A) For individuals age 18 years and younger, failure to respond to a post-eligibility RFI for income verification will not result in termination of benefits; eligibility will be maintained through the 12-month Continuous Eligibility period (see OAR 410-200-0135) or the end of the month in which they turn 19 years of age, whichever is earlier;

(B) For pregnant individuals, failure to respond to a post-eligibility RFI for income verification will not result in termination of benefits; eligibility will be maintained through the duration of pregnancy and the postpartum eligibility period (see OAR 410-200-0135).

(8) Recipients who are determined ineligible for ongoing HSD Medical Benefits will be provided 60-day advance notice of termination or reduction of coverage and referred to the Federally Facilitated Marketplace as described in OAR 410-200-0100, if applicable.

History

Statutory/Other Authority: ORS 411.402
Statutes/Other Implemented: ORS 411.402
DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 11-2023, adopt filed 03/30/2023, effective 04/01/2023