Or. Admin. R. 410-133-0090 - Public Education Agency School Medical Provider Payment Requirements

Current through Register Vol. 60, No. 12, December 1, 2021

These rules are designed to assist the public Education Agency (EA) School Medical (SM) provider in matching state and federal funds for services defined by Section 1915(g) of the Social Security Act, 42 USC | 1396n(g) and are to be used in conjunction with the Division of Medical Assistance Programs (Division) General Rules (chapter 410 division 120).

(1) Payment will be made in accordance with Department of Human Services Provider Rules Chapter 407 Division 120 and Division General Rules Chapter 410 Division 120 to the enrolled School Medical (SM) provider with the Oregon Health Authority (Authority), also termed Department, meeting the requirements set forth in the provider enrollment agreement for those covered health services provided by medically qualified staff working within the scope of their practice. Medically qualified staff must meet the qualifications as outlined in OAR 410-133-0120 Medically Qualified Staff.
(2) Signing the school medical provider enrollment agreement sets forth the relationship between the State of Oregon, the Authority, and the SM provider and constitutes agreement by the SM provider to comply with all applicable rules of the Authority, the Division, and federal and state laws or regulations. (See OARs chapter 407 division120 and Division General Rules chapter 410 division 120).
(3) The school medical (SM) provider will bill for covered services provided to Medicaid-eligible students in accordance with Authority chapter 407 division 120 Provider rules, the Division rules chapter 410 division 120 and these School-Based Health Services (SBHS) rules. Payments will be made through the Medicaid Management Information System (MMIS) and the SM provider must retain the full payment for the covered services provided. The SM provider must have a Trading Partner Agreement (TPA) with the Authority prior to submission of electronic transactions.
(4) School-based health services (SBHS) authorized under these rules is a cost-sharing Federal Financial Participation (FFP) matching program in which the Education Agency (EA) SM provider that is a public entity unit of government, is responsible for paying the non-federal matching share of the amount of the SBHS claims, calculated using the Federal Medical Assistance Percentage (FMAP) rates in effect during the quarter when the SBHS claims will be paid:
(a) The unit of government public education agency SM provider's share means the public funds share of the Medicaid payment amount. Pursuant to 42 CFR 433.51, public funds may be considered as the State's share in claiming federal financial participation (FFP) if the public funds meet the following conditions:
(A) The public funds are transferred to the Authority from public entities that are units of government;
(B) The public funds are not federal funds or they are federal funds authorized by federal law to be used to match other federal funds;
(C) All sources of funds must be allowable under 42 CFR 433.51 Subpart B;
(b) The unit of government EA SM provider must pay its non-federal matching share portion for claims submitted to the Authority in accordance with OAR 410-120-0035.
(5) Before the Authority pays for SBHS claims, the Authority must receive the SM provider's corresponding local match payment as described in this rule. Failure to timely pay the non-federal matching funds to the Authority will delay reimbursement of claims and may require the SM provider to resubmit the claims.
(6) The Authority will not be financially responsible for payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid program. If the Authority has previously paid the SM provider for any claim which the CMS disallows, the SM provider must reimburse the Authority the amount of the claim that the Authority has paid to the SM provider, less any amount previously paid by the unit of government EA SM Provider to the Authority for purposes of reimbursing the Authority for the non-federal match portion of that claim.


Or. Admin. R. 410-133-0090
HR 39-1991, f. & cert. ef. 9-16-91; HR 41-1992, f. 12-31-92, cert. ef. 1-1-93; OMAP 31-1998, f. & cert. ef. 9-1-98; OMAP 88-2003(Temp), f. & cert. ef. 12-15-03 thru 5-15-04; OMAP 4-2004, f. 1-23-04, cert. ef. 2-1-04; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08; DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert.ef. 7-1-09

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 413.042 & 414.065

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