Or. Admin. R. 410-120-1210 - [Effective7/6/2022]Medical Assistance Benefit Packages and Delivery System
Current through Register Vol. 61, No. 4, April 1, 2022
(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 he
or she is 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 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.
(D) Limitations: The following services have
limited coverage for non-pregnant adults age 21 and older. (Refer to the cited
OAR chapters and divisions for details):
(i)
Selected dental (OAR chapter 410, division 123);
(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).
(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 will 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)
Citizen/Alien-Waived Emergency Medical (CAWEM):
(A) Benefit Package identifier CWM;
(B) Eligibility criteria: Eligible clients
are non-qualified aliens that are 19 years and older, not eligible for other
Medicaid programs solely because they do not meet the citizen and immigration
status requirement pursuant to Oregon Administrative Rules (OAR)
410-200-0215;
(C) Coverage is
limited to:
(i) Emergency medical services as
defined by
42 CFR
440.255: Sudden onset of a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that the absence of immediate medical attention could reasonably be
expected to result in: placing the patient's health in serious jeopardy,
serious impairment to bodily functions, or serious dysfunction of any bodily
organ or part (the "prudent layperson standard" does not apply to the CAWEM
emergency definition);
(I) The Authority
determines if the primary condition requiring treatment meets the definition of
an emergency medical condition in
42 CFR
440.255, and the condition is confirmed
through review of clinical records;
(II) The Authority pays for all related
medically necessary health care services and professional services provided.
These services include, but are not limited to such things as Anesthesia,
surgical, and recovery services; Emergency medical transportation; Laboratory,
x-ray, and other diagnostics and the professional interpretations; Medical
equipment and supplies; Medications.
(ii) Labor and Delivery.
(iii) Emergency Dialysis to treat acute renal
failure or end stage renal disease is considered an emergency and is covered
under CAWEM emergency assistance, when received through a hospital emergency
department or Hospital facility, which includes fistula placement and other
required access. OHA does not pay for diagnostics or predialysis intervention,
such as surgery for fistula placement anticipating the need for dialysis, or
any services related to preparing for dialysis under CAWEM emergency
assistance.
(D)
Exclusions: The following services are not covered even if they are sought as
emergency services:
(i) Prenatal or postpartum
care;
(ii) Sterilization;
(iii) Family Planning;
(iv) Preventive care;
(v) Organ transplants and transplant-related
services, including pre-evaluations and post-operative care;
(vi) Chemotherapy;
(vii) Hospice;
(viii) Home health;
(ix) Private duty nursing;
(x) Eyeglasses and exams;
(xi) Dental services provided outside of an
emergency department hospital setting;
(xii) Outpatient drugs or over-the-counter
products, except when prescribed on the same day and associated with the
qualifying emergency service;
(xiii) Non-emergency medical
transportation;
(xiv) Therapy
services;
(xv) Durable medical
equipment and medical supplies;
(xvi) Rehabilitation services.
(e) CAWEM Reproductive
Health Equity Fund (RHEF) benefit:
(A) Benefit
Package identifier CWM;
(B)
Eligibility criteria: Eligible clients are those individuals eligible under the
CAWEM benefit in subsection (d) of these rules;
(C) Coverage: This is a state-funded women's
reproductive health benefit administered by the Public Health Division. For
full coverage and criteria, refer to OAR chapter 333, division 004. The Health
Systems Division administers a subset of the benefits described in OAR chapter
333, division 004 as follows:
(i) Abortion
services occurring in a hospital;
(ii) Sterilization.
(f) CAWEM Plus:
(A) Benefit Package identifier code
CWX;
(B) Eligibility criteria: As
defined in federal regulations and in the Children's Health Insurance Program
(CHIP) state plan, eligible clients are non-qualified aliens that are pregnant
women, 19 years and older, at or below 185 percent of the Federal Poverty Level
(FPL), and not eligible for other Medicaid programs solely because they do not
meet the citizen and immigration status requirement, pursuant to Oregon
Administrative Rules (OAR) 410-200-0215;
(C) Coverage includes: services covered by
OHP Plus as described above;
(D)
Exclusions: The following services are not covered for this program:
(i) Postpartum care (except when provided and
billed as part of a global obstetric package code that includes the delivery
procedure);
(ii)
Sterilization;
(iii)
Abortion;
(iv) Death with dignity
services;
(v) Hospice.
(E) The day after pregnancy ends,
eligibility for medical services shall be based on eligibility categories
established in OAR chapters 461 and 410.
(g) CAWEM Plus RHEF benefit:
(A) Benefit Package identifier code
CWX;
(B) Eligibility criteria:
Eligible clients are CAWEM pregnant women not eligible for Medicaid based on
immigration status, at or below 185 percent of the Federal Poverty Level (FPL).
These Qualified aliens eligible for the CAWEM Plus prenatal program are also
eligible for a state-funded benefit pursuant to ORS
414.432;
(C) Coverage includes:
(i) Postpartum care delivered outside of the
global obstetric package not included under the CAWEM Plus benefit, 60 days
following the pregnancy end date. Postpartum eligibility period is as described
in OAR 410-200-0240;
(ii) Services
covered by OHP Plus for 60 days following the pregnancy end date as described
in (4)(a)(C) of these rules;
(iii)
Services as described in subsection (e)(C) of these rules.
(h) Cover All Kids benefit:
(A) Benefit Package identifier code BMH, PERC
CK, CL, CM, CN, CO, CP, CR;
(B)
Eligibility criteria: Eligible clients are non-qualified aliens that are under
age 19, not eligible for other Medicaid programs solely because they do not
meet the citizen and immigration status requirement pursuant to Oregon
Administrative Rules (OAR) 410-200-0215. Coverage is a state funded medical
benefit pursuit to ORS
414.231;
(C) Coverage is an OHP Plus equivalent
benefit that 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 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 for clients enrolled in a CCO.
(5) Division clients are enrolled
for covered health 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 or dental care.
(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 can 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.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065, 414.329, 414.706, 414.710, 414.231 & 414.432
The following state regulations pages link to this page.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.