Or. Admin. Code § 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;
(C) Coverage includes:
(i) Services above the funding line on the
Health Evidence Review Commission (HERC) Prioritized List of Health Services
(Prioritized List), (OAR
410-141-3820 through
410-141-3830);
(ii) Ancillary services, (OAR
410-141-3820);
(iii) Substance use disorder treatment and
recovery services provided through local substance use disorder treatment and
recovery providers;
(iv) 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;
(v) Hospice;
(vi) Post-hospital extended care benefit up
to a twenty (20) 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
(vii) HRSN Services (OAR
410-120-2005).
(D) Limitations: Except for YSHCN
Members, 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;
(C) Coverage includes:
services covered by Medicare and OHP Plus as described in this rule;
(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.
(c) Qualified Medicare Beneficiary
(QMB)-Only:
(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.
Notes
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
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