Or. Admin. Code § 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);
(c) Substance Use Disorder treatment
services:
(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 and 141 and 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.
Notes
Publications: Publications referenced are available from the agency.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
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