justicedao/ipfs_state_laws huggingface dataset:
333-004-3190 Compliance with Federal and State Statutes (1) Agencies are required to comply with the applicable sections of the federal and state statutes referenced in this rule. (a) 5 CFR Part 84 that implements Title V, section 504 of the Rehabilitation Act of 1973, as amended; (b) Title II and Title III of the Americans with Disabilities Act of 1991; (c) Title VI and VII of the Civil Rights Act of 1964, as amended; (d) 42 CFR Part 493 Laboratory Requirements and ORS chapter 438 (Clinical Laboratories); (e) The Age Discrimination in Employment Act of 1967, as amended, and the Age Discrimination Act of 1975, as amended; (f) The Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended; and (g) Health Insurance Portability and Accountability Act (HIPAA) regarding the confidentiality of client records; (h) All applicable federal and state laws and regulation pertaining to the provision of Medicaid Services under the Medicaid Act, Title XIX, 42 U.S.C. Section 1396 et. seq.; (i) All applicable laws and regulations pertaining to Title XVIII, XIX, or XX of the Social Security Act; and (j) All other applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations. (2) Providers described in ORS chapter 419B are required to report suspected child abuse or neglect to their local child welfare office of the Department of Human Services or police, in the manner described in ORS chapter 419B. (3) The Clinical Laboratory Improvement Act (CLIA), requires all entities that perform even one laboratory test, including waived tests, on materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings to meet certain federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory. (4) Clinics that dispense medications may require registration and compliance with applicable rules of the Oregon Board of Pharmacy, OAR 855-043-0002 through 855-043-0750. (5) An individual enrolling or re-enrolling in the RH Access Fund shall be given the opportunity to register to vote through completion of the RH Access Fund enrollment form, as applicable. Agencies are required to comply with all relevant National Voter Registration Act rules in OAR 165-005-0060 through 165-005-0070. Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149, ORS 435.205 & ORS 435.230 Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032, ORS 435.205 & ORS 435.230 History: PH 95-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 194-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3200 Grounds for Agency Sanctions; Sanctions (1) The following may result in the imposition of a sanction against an agency: (a) Interference with the investigation of health care fraud; (b) Conviction for unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance; (c) An action by a state licensing authority relating to a provider's professional competence, professional conduct, or financial integrity, that results in the provider either: (A) Having their license suspended or revoked; or (B) Surrendering the license while a formal disciplinary proceeding was pending before a licensing authority. (d) Suspension or exclusion from participation in a federal or state-administered health care program for reasons related to professional competence, professional performance, or other reason; (e) Threatening, intimidating or harassing clients or their relatives in an attempt to influence payment rates or affect the outcome of disputes between the provider and the RH Program; (f) Participation in collusion that resulted in an inappropriate money flow between the parties involved, for example, referring clients unnecessarily to another provider; (g) For claims paid using CCare funds, any sanctions outlined in OAR 410-120-1400 (HSD Medicaid Programs, General Administrative Rules); (h) Unauthorized or unlawful disclosure of client information; and (i) Failure to comply with these rules. (2) The RH Program shall consider the following factors in determining whether to issue a sanction and the sanction to be imposed: (a) Nature of the violation or offense; (b) Extent of the violations by the agency; (c) History of prior violations by the agency; (d) Prior imposition of sanctions; (e) Prior notification of compliance findings; and (f) Cooperation with an investigation. (3) Sanctions may include one or more of the following: (a) Termination of certification; (b) Imposition of a Corrective Action Plan; (c) A requirement to attend provider education sessions at the expense of the sanctioned agency; (d) A requirement that payment for certain services are made only after the RH Program has reviewed documentation supporting the services; and (e) For claims paid using CCare funds, any action authorized under OAR 410-120-1460 (HSD Provider Sanctions). Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149, ORS 435.205 & ORS 435.230 Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032, ORS 435.205 & ORS 435.230 History: PH 96-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 202-2022, amend filed 10/27/2022, effective 10/27/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3220 Agency Requests for Contested Case Hearings (1) An applicant agency or an agency may request a contested case hearing: (a) If a new or renewal application for certification is denied. (b) If the RH program proposes to terminate an agency’s certification. (2) An applicant agency or an applicant agency must request a hearing in writing within 30 calendar days of the date the denial or termination notice was mailed. (3) Contested cases will be conducted in accordance with the Attorney General’s Model Rules, OAR 137-003-0501 through 137-003-0700. (4) The party to an agency contested case hearing is the agency who requested the appeal. Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149, ORS 435.205 & ORS 435.230 Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032, ORS 435.205 & ORS 435.230 History: PH 98-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 196-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3230 Discretionary Use of Funds The RH Program may, at its discretion, use RH GF or Title X instead of CCare to reimburse an agency for CCare-covered services, referenced in OAR 333-004-3070(3)(a) (RH Access Fund Covered Services by Funding Source), provided to clients who may otherwise be eligible for CCare, in which case OAR 333-004-3090(1)(b) (Client Eligibility for the RH Access Fund) will not apply. Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149, ORS 435.205 & ORS 435.230 Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032, ORS 435.205 & ORS 435.230 History: PH 99-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 202-2022, amend filed 10/27/2022, effective 10/27/2022 PH 50-2022, temporary amend filed 04/29/2022, effective 05/01/2022 through 10/27/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-4000 Description of Abortion Access Plan The purpose of OAR 333-004-4000 through 333-004-4130 is to establish requirements for the Abortion Access Plan under which authorized providers and agencies may receive reimbursement from the Oregon Health Authority for abortion services provided to individuals enrolled in health benefit plans described in ORS 743A.067(7)(e) and (9). Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 100-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4010 Definitions As used in OAR 333-004-4000 through 333-004-4130, the following definitions apply: (1) “Abortion Access Plan” means the program, administered by the Reproductive Health Program (RH Program), under which authorized providers and agencies may bill and receive reimbursement for abortion services provided to eligible clients. (2) “Abortion services” means procedural abortions, medication abortions, anesthesia, and long-acting reversible contraceptive (LARC) insertions associated with abortion visits. (3) “Authorized agency” means an entity that has met the criteria outlined in OAR 333-004-4050. (4) “Authorized provider” means a provider who has met the criteria outlined in OAR 333-004-4050. (5) “ Claims form ” means the mechanism by which authorized providers bill the RH Program for abortion services provided to eligible clients. (6) “Eligible client” means a client who is enrolled in a health plan that excludes coverage for abortion services per ORS 743A.067(7)(e) and (9). (7) “Entity” means a business entity offering health care services that includes abortion services. (8) “Provider” means a health care provider licensed in the state in which they are practicing, with a scope of practice that includes the provision of the abortion services for which the provider is seeking reimbursement and who is qualified to perform the abortion services for which the provider is seeking reimbursement. (9) "Reproductive Health Program" or "RH Program" means the program within the Center for Prevention and Health Promotion (Center) of the Oregon Health Authority that administers the Abortion Access Plan. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 101-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4020 Covered Services The Abortion Access Plan covers abortion services. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 102-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4030 Excluded Services Services not listed as covered services in OAR 333-004-4020 are not covered by the Abortion Access Plan. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 103-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4040 Client Eligibility To be eligible to have abortion services covered by the Abortion Access Plan, an individual must: (1) Be an eligible client; and (2) Have received services from an authorized agency or authorized provider that submits a claim for reimbursement using the RH Program-approved Abortion Access Plan claims form. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 104-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4050 Eligibility for Reimbursement (1) To be considered an authorized agency or authorized provider and certified to receive reimbursement for abortion services covered by the Abortion Access Plan for clients an entity or provider must: (a) Be enrolled with the Oregon Health Authority, Health Systems Division and have met all requirements outlined in OAR 410-120-1260; (b) Be certified with the RH Program as an AbortionCare agency per OAR 333-004-3030(3); or (c) Have an active vendor account with the State of Oregon. (2) An entity or provider will not be considered authorized if they have been suspended or terminated by Oregon from participation in a federal or state medical program administered by the State of Oregon, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, except for those services or supplies provided prior to the date of suspension or termination. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 105-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4060 Abortion Access Plan Billing and Claims (1) An authorized agency or authorized provider shall complete all required fields on the Abortion Access Plan claims form prior to submission to the RH Program. (2) An authorized agency or authorized provider must not seek payment from an eligible client, or from a financially responsible relative or representative of that eligible client, for any services covered by the Abortion Access Plan. The authorized agency or authorized provider shall accept reimbursement from the RH Program for any covered services as defined in OAR 333-004-4020 (Covered Services) as payment in full. (a) An eligible client may be billed for services that are not covered by Abortion Access Plan, unless the authorized agency or provider misrepresented coverage of the service to the eligible client. (b) Eligible clients must be informed by the authorized agency or authorized provider prior to their visit that they may be billed for services not covered by the Abortion Access Plan. (c) Authorized agencies or authorized providers may not request a deposit from the eligible client in advance of services covered by the Abortion Access Plan. (3) By submitting a claim to the RH Program for payment, the authorized agency or authorized provider is certifying that the information is true, accurate, and complete. (a) All billings must be for services provided within the agency’s and provider’s licensure or certification. (b) A claim may not be submitted prior to providing services. (4) An authorized agency or authorized provider may not submit to the RH Program: (a) Any false claim for payment. (b) Any claim altered in such a way as to result in a payment for a service that has already been paid. (c) Any claim upon which payment has already been made by the RH Program or another source unless the amount paid is clearly entered on the claim form. (d) Any claim or written orders contrary to generally accepted standards of medical practice. (e) Any claim for services that exceed what has been requested or agreed to by the eligible client or the responsible relative or guardian or requested by another medical practitioner. (f) Any claim for services provided to persons who were not eligible. (g) Any claim that overstate or misrepresent the level, amount or type of health care provided. (5) An agency or provider is required to correct the billing error or to refund the amount of the overpayment, on any claim where the agency or provider identifies an overpayment made by the RH Program. (6) No authorized agency or authorized provider shall submit claims that result in: (a) Receiving payments for services provided to individuals who were not eligible; or (b) Establishing multiple claims that overstate or misrepresent the level, amount, or type of health care provided. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 106-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4070 Timely Submission of Claims (1) Claims are processed once a month. To be included in a given month’s processing, an authorized agency or authorized provider must submit a claim to the RH Program using the Abortion Access Plan claims form by electronic mail before the monthly processing deadline. (2) The RH Program shall pay claims within 12 months of the date of service. Claims submitted more than 12 months after the date of service shall be rejected. (3) Errors causing rejection of any claim must be resolved by the authorized agency or authorized provider within 12 months of the date of service. Claims older than 12 months submitted by the agency or provider to the RH Program shall not be paid, except when the RH Program has made an error that caused the agency or provider not to be able to bill within 12 months of the date of service. The error must be confirmed by the RH Program before the claim shall be paid. (4) Authorized agencies or authorized providers may void claims at any time after the date of service. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 107-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4080 Payment for Abortion Access Plan Claims (1) The RH Program shall make payments to an authorized agency or authorized provider that actually performs the services for clients. (2) Reimbursement rates for abortion services are set by the RH Program. Claims are reimbursed at the rates in effect on the date of service. (3) The RH Program will not make payment on claims that have been assigned, sold, or otherwise transferred. This includes, but is not limited to, transfer to a collection agency or party who advances money to an agency for accounts receivable. (4) The RH Program shall only pay for services that are adequately documented and for drug, device, and supply costs that are supported by invoice. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 108-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4090 Review or Audit of Abortion Access Plan Claims (1) A RH Program staff person, contractor, or auditor may review a claim for assurance that: (a) Specific medical services, drugs, devices, or supplies were provided to clients by an authorized agency or authorized provider in accordance with OAR 333-004-4040 (Client Eligibility); and (b) The services, drugs, devices, or supplies were provided in accordance with Abortion Access Plan rules. (2) To determine the number of inappropriate claims, and subsequently the overpayment amount, the RH Program may review a statistically valid random sample of claims with sufficient sample size for a confidence interval of 95 percent. (3) The RH Program may deny payment or seek recovery of payment if a review or audit determines the visit does not include a covered services(s) referred to in OAR 333-004-4120 (Grounds for Sanctions; Sanctions). (4) The RH Program shall notify the authorized agency or authorized provider, in writing, of the improper billing findings and subsequent actions to be taken by the authorized agency or authorized provider to correct the identified findings and any sanctions that may be imposed by the RH Program. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 109-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4100 Claim Re-Determination (1) If an authorized agency or authorized provider disagrees with an initial claim determination, it may request a review for re-determination of the denied claim payment. The request to open an initial claim determination for a re-determination review must be made to the RH Program in writing, within 60 calendar days from the date of the original claim adjudication date. (2) All requests must contain a detailed letter of explanation identifying the specific re-determination denial issue and alleged error. This information must be submitted to the RH Program at the time of the request. (3) At the time the request for re-determination is made an authorized agency or authorized provider is responsible for providing the information needed to adjudicate its claim, including relevant health records The RH Program may request additional information that it finds relevant to the review. An authorized agency or authorized provider requesting a re-determination review must include the following: (a) The specific service, supply or item being denied and a detailed justification for the re-determination of the denied service; (b) A copy of the original claim and a copy of the original denial notice or remittance advice that describes the basis for the claim denial under re-determination; and (c) Any information or medical documentation pertinent to support the request and to obtain a resolution of the re-determination review dispute. (4) A re-determination review is based on RH Program review of documentation and applicable law. The RH Program does not provide a face-to-face meeting with an authorized agency or authorized provider as part of the re-determination process. (a) The authorized agency or authorized provider is responsible for the timely submission of review request and all information pertinent to conducting the review and consistent with the requirements of this rule. (b) The RH Program shall notify an authorized agency or authorized provider requesting review that the re-determination request has been denied if: (A) The authorized agency or authorized provider did not submit a timely request; (B) The required information is not provided at the same time the request is submitted; or (C) The authorized agency or authorized provider fails to submit any additional requested information within 14 business days of request. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 110-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023
333-004-4120 Grounds for Sanctions; Sanctions (1) The following may result in the imposition of a sanction against an authorized agency or authorized provider: (a) Interference with the investigation of health care fraud; (b) Conviction for unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance; (c) An action by a state licensing authority relating to a provider's professional competence, professional conduct, or financial integrity, that results in the provider either: (A) Having their license suspended or revoked; or (B) Surrendering the license while a formal disciplinary proceeding was pending before a licensing authority. (d) Suspension or exclusion from participation in a federal or state-administered health care program for reasons related to professional competence, professional performance, or other reason; (e) Threatening, intimidating, or harassing clients or their relatives; (f) Participation in collusion that resulted in an inappropriate money flow between the parties involved, for example, referring clients unnecessarily to another provider; (g) Submittal of fraudulent claims; (h) Unauthorized or unlawful disclosure of client information; or (i) Failure to comply with OAR 333-004-4000 through 333-004-4130. (2) The RH Program shall consider the following factors in determining whether to issue a sanction and the sanction to be imposed: (a) Nature of the violation or offense; (b) Extent of the violations; (c) History of prior violations; (d) Prior imposition of sanctions; (e) Cooperation with an investigation; and (f) Whether the action, sanction or exclusion was the result of a state having passed a law making abortion services unlawful. (3) Sanctions may include one or more of the following: (a) A requirement that payment for certain services are made only after the RH Program has reviewed documentation supporting the services. (b) Prohibition from receiving payment for abortion services under the Abortion Access Plan in the future. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 112-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, adopt filed 09/28/2023, effective 10/01/2023