Or. Admin. Code § 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;
(C) Telemedicine as described in OAR
410-120-1990; and
(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;
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065 & ORS 414.025
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