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.

Notes

Or. Admin. R. 410-124-0010

HR 37-1990, f. 11-6-90, cert. ef. 11-9-90; HR 17-1992, f. & cert. ef. 7-1-92; HR 4-1994, f. & cert. ef. 2-1-94; HR 19-1995, f. 9-28-95, cert. ef. 10-1-95; OMAP 18-2000 f. 9-28-00, cert. ef. 10-1-00; DMAP 22-2022, minor correction filed 02/16/2022, effective 2/16/2022; DMAP 2-2023, temporary amend filed 01/31/2023, effective 2/1/2023through 7/30/2023; DMAP 49-2023, amend filed 06/30/2023, effective 7/1/2023

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.065