justicedao/ipfs_state_laws huggingface dataset:
410-130-0585 Family Planning Services (1) Family planning services are those intended to prevent or delay pregnancy, or otherwise control family size. (2) The Division of Medical Assistance Programs (Division) covers family planning services for clients of childbearing age (including minors who are considered to be sexually active). (3) Family Planning services include: (a) Annual exams; (b) Contraceptive education and counseling to address reproductive health issues; (c) Laboratory tests; (d) Radiology services; (e) Medical and surgical procedures, including tubal ligations and vasectomies; (f) Pharmaceutical supplies and devices. (4) Clients may seek family planning services from any provider enrolled with the Division, even if the client is enrolled in a Prepaid Health Plan (PHP). Reimbursement for family planning services is made either by the client’s PHP or the Division. If the provider is: (a) A participating provider with the client’s PHP, bill the PHP; (b) An enrolled Division provider, but is not a participating provider with the client’s PHP, bill the Division and add modifier –FP to the billed code. (5) Family planning methods include natural family planning, abstinence, intrauterine device, cervical cap, prescriptions, sub-dermal implants, condoms, and diaphragms. (6) Bill all family planning services with the most appropriate ICD-10-CM diagnosis code the most appropriate CPT or HCPCS code and add modifier –FP. (7) For annual family planning visits use the appropriate CPT code in the Preventative Medicine series (9938X-9939X) and add modifier -FP. These codes include comprehensive contraceptive counseling. (8) When comprehensive contraceptive counseling is the only service provided at the encounter, use a CPT code from the Preventative Medicine, Individual Counseling series (99401-99404) and add modifier -FP. (9) Bill contraceptive supplies with the most appropriate HCPCS codes. (10) Where there are no specific CPT or HCPCS codes, use an appropriate unlisted code and add modifier -FP. Bill supplies at acquisition cost. [ED. NOTE: Forms referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.152 History: DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15 DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11 OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06 OMAP 45-2005, f. 9-9-05, cert. ef. 10-1-05 OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03 OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 51-2002, f. & cert. ef. 10-1-02 OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02 OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01 OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 17-1999, f. & cert. ef. 4-1-99 OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98 HR 4-1997, f. 1-31-97, cert. ef. 2-1-97 HR 10-1996, f. 5-31-96, cert. ef. 6-1-96 HR 42-1994, f. 12-30-94, cert. ef. 1-1-95 HR 6-1994, f. & cert. ef. 2-1-94 HR 40-1992, f. 12-31-92, cert. ef. 2-1-93 HR 8-1992, f. 2-28-92, cert. ef. 3-1-92 HR 43-1991, f. & cert. ef. 10-1-91 HR 19-1991, f. 4-12-91, cert. ef. 5-1-91
410-130-0670 Death With Dignity (1) All Death with Dignity services must be billed directly to the Division of Medical Assistance Programs (Division), even if the client is in a managed care plan. (2) Death with Dignity is a covered service, incorporated in the "comfort care" condition/treatment line on the Health Services Commission's Prioritized List of Health Services. (3) The following physician visits and medical encounters are billable when performed by a licensed physician or psychologist: (a) The medical confirmation of the terminal condition; (b) The two visits in which the client makes the oral request; (c) The visit in which the written request is made; (d) The visit in which the prescription is written; (e) Counseling consultation(s); and (f) Medication and dispensing. (4) More than one of the services listed in sections (3)(a) through (3)(f) may be provided during the same visit. Additional visits for discussion or counseling are also covered for payment. (5) Billing: (a) All claims for Death with Dignity services must be made on a paper CMS-1500 billing form; (b) Do not submit a claim for Death with Dignity services electronically or on an 837P; (c) Claims must be submitted using appropriate CPT or HCPCS codes; (d) The Division unique diagnosis code PAD-00 must be entered in Field 21 of the CMS-1500 billing form. Do not list any additional diagnosis codes in this field; (e) Claims must be submitted only on paper to: Division, PO Box 992, Salem, Oregon 97308-0992; (f) Prescriptions must be billed only with the Division unique code 8888-PAID-00. This code must be entered in Field 24D of the CMS-1500. In addition, the actual NDC number of the drug dispensed and the dosage must be listed below the prescription code; (g) the Division may be billed for prescription services only when the pharmacy has been properly notified by the physician in accordance with OAR 847-015-0035. This OAR requires the physician to have the client's written consent to contact and inform the pharmacist of the purpose of the prescription. [ED. NOTE: Forms referenced available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06 OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 2-2000, f. 3-31-00, cert. ef. 4-1-00 OMAP 17-1999, f. & cert. ef. 4-1-99 OMAP 46-1998, f. & cert. ef.12-1-98
410-132-0020 Private Duty Nursing Services (1) The practice of nursing is governed by the following: Oregon State Board of Nursing, ORS 678.010 to 678.410, and Oregon State Board of Nursing, chapter 851, divisions 031, 045, and 047. (2) Private duty nursing is considered supportive to the care provided to a client by the client's family, foster parents, and delegated caregivers, as applicable. Nursing services shall be medically appropriate. Medically appropriate for private duty nursing shift care is determined by qualifying for services based on the Private Duty Nursing Acuity Grid (DMAP 591). Increases or decreases in the level of care and number of hours or visits authorized shall be based on a change in the client’s condition, program limitations, and the family, foster parents, or delegated caregiver’s ability to provide care. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 45-2015, f. & cert. ef. 8-25-15 OMAP 54-2002, f. & cert. ef. 10-1-02 OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00 OMAP 6-1999, f. 3-4-99, cert. ef. 4-1-99 HR 6-1997, f. & cert. ef. 2-19-97
410-132-0060 Private Duty Nursing Transition into Maintenance (1) Private duty nursing services become maintenance care when any one of the following situations occurs: (a) Medical and nursing documentation supports that the condition of the client is stable/predictable; (b) The plan of care does not require a licensed nurse to be in continuous attendance; (c) The client, family, foster parents, or caregivers have been taught the nursing services and have demonstrated the skills and ability to carry out the plan of care; (d) The combined score on the Acuity Grid and Psychosocial Grid is less than 54. (2) This rule does not apply to individuals in the MFC program. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 45-2015, f. & cert. ef. 8-25-15 HR 6-1997, f. & cert. ef. 2-19-97 HR 9-1991, f. 1-28-91, cert. ef. 3-1-91
410-132-0100 Prior Authorization (1) Private duty nursing providers shall obtain prior authorization (PA) for all services. (2) Providers shall request PA as follows (see the Private Duty Nursing Services Supplemental Information booklet for contact information): (a) For individuals served by the MFC), from the Department‘s MFC Program; (b) For clients enrolled in the fee-for-service (FFS) Medical Case Management (MCM) program, from the MCM contractor; (c) For members enrolled in a coordinated care organization (CCO) or prepaid health plan (PHP), from the CCO or the PHP; (d) For all other clients, from the Division. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 45-2015, f. & cert. ef. 8-25-15 DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08 OMAP 93-2003, f. 12-30-03 cert. ef. 1-1-04 OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00 OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99 HR 6-1997, f. & cert. ef. 2-19-97 HR 9-1991, f. 1-28-91, cert. ef. 3-1-91, Renumbered from 461-019-0210 AFS 40-1984, f. 9-18-84, ef. 10-1-84 AFS 22-1984(Temp), f. & ef. 5-1-84 AFS 14-1984(Temp), f. & ef. 4-2-84 AFS 9-1983, f. 2-17-83, ef. 3-2-83 AFS 52-1982, f. 5-28-82, ef. 6-30-82 AFS 43-1982, f. 4-29-82, ef. 5-1-82 PWC 799, f. & ef. 6-1-76 PWC 759, f. 9-5-75, ef. 10-1-75 PWC 681, f. & ef. 7-17-74
410-132-0120 Billing Information (1) If the client has not enrolled in a CCO or PHP, bill with the appropriate Division unique procedure codes and follow the instructions on how to complete the CMS-1500. (2) Client copayments may be required for certain services. See OAR 410-120-1230 for specific details. (3) Claims shall be submitted on a CMS-1500, electronically or on paper. Paper claims shall be sent to the Division. (4) Contact the Division’s Electronic Billing Representative for information about electronic billing. (5) Bill on a CMS-1500 and enter the appropriate TPR Explanation Code in Field 9 when billing for clients with Medicare. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 45-2015, f. & cert. ef. 8-25-15 OMAP 54-2002, f. & cert. ef. 10-1-02 HR 6-1997, f. & cert. ef. 2-19-97 HR 9-1991, f. 1-28-91, cert. ef. 3-1-91
410-132-0180 Procedure Codes (1) All private duty nursing services require prior authorization. (2) Private duty nursing visit: (a) T1030 — Nursing care in the home by registered nurse per diem; (b) T1031 — Nursing care in the home by licensed practical nurse per diem. (3) Private duty nursing shift care: (a) S9123 — Nursing care in the home by registered nurse per hour — 1 unit equals one hour; (b) S9124 — Nursing care in the home by licensed practical nurse per hour — 1 unit equals one hour. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 45-2015, f. & cert. ef. 8-25-15 OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 54-2002, f. & cert. ef. 10-1-02 OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00 HR 6-1997, f. & cert. ef. 2-19-97 HR 9-1991, f. 1-28-91, cert. ef. 3-1-91
410-132-0200 Provider Enrollment (1) Registered nurses and licensed practical nurses shall submit a copy of licensure every two years upon renewal by the Oregon State Board of Nursing to be enrolled or continue enrollment as a Division provider. (2) If the Division provider is a nursing employment/staffing agency, the agency shall: (a) Be licensed in the State of Oregon as an in-home care agency with a comprehensive licensure as defined in OAR 333-536 or Home Health Agency OAR 333-027; (b) Conduct a background check through the Department CRIMS; (c) Provide a copy of the state licensure to the Authority upon request. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 45-2015, f. & cert. ef. 8-25-15 OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00 OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99
410-133-0000 Purpose (1) School-Based Health Services (SBHS) rules: (a) Define Oregon’s fee-for-service Medicaid program administered by the Oregon Health Authority (Authority) to reimburse publicly funded education agencies for health services provided in education settings to Oregon’s Medicaid-enrolled children and young adults. (b) Define when Medicaid-covered services are reimbursable to education agencies. (c) Define the reimbursement methodology for services rendered in education settings. (d) Cite and align with federal and state requirements and limitations including: (A) Individuals with Disabilities Education Act (IDEA); (B) Section 504 of the Rehabilitation Act of 1973; (C) Title XIX and Title XXI of the Social Security Act; (D) Oregon Revised Statutes; and (E) Oregon Administrative Rules (OARs). (2) These SBHS rules are to be used in conjunction with: (a) Medical Assistance Programs rules in OARs Chapter 410, Divisions 120 and 141; (b) The Authority provider rules in OARs Chapter 943, Division 120; and (c) Oregon Department of Education’s (ODE) rules in: (A) OARs Chapter 581, Divisions 15, 21, and 22; and (B) OARs Chapter 584, Divisions 220 and 245. (3) Medicaid-enrolled children and young adults retain the ability to obtain services from any qualified Medicaid provider. These rules do not require Medicaid-enrolled children and young adults to receive their health services only from school medical providers. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 31-2003, f. & cert. ef. 4-1-03 OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00 OMAP 38-1999, f. & cert. ef. 10-1-99 HR 39-1991, f. & cert. ef. 9-16-91
410-133-0050 Individual Plan of Care (1) School-based health services, except unplanned services and screenings, must be provided pursuant to, in relation to, or in the development of a Medicaid-enrolled child or young adult’s Individual Plan of Care (IPOC). (2) The IPOC must contain the following: (a) The effective date of the IPOC. If a new IPOC is established, the new IPOC must indicate the new effective date, and an end date must be listed on the previous IPOC; (b) The specific child or young adult’s first and last name; (c) The education agency’s name; and (d) Each health service category including the nature, extent, or units of service and therapeutic value for each service. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, adopt filed 09/06/2024, effective 09/06/2024
410-133-0060 School-Based Health Services (1) School-based health services are provided in education settings in support of a child or young adult’s education to address health-related service needs and devices that help the individual child or young adult keep, learn, or improve skills and functioning that adversely affect individual educational performance. (2) Education agencies may be reimbursed for the following services subject to the requirements in OAR 410-133-0080 and 410-133-0090. (a) Evaluations, re-evaluations, and assessments; (b) Care coordination and referrals; (c) Direct assistance with selection, acquisition, or use of assistive technology; (d) Audiology services; (e) Behavioral health services; (f) Dental services; (g) Diagnostic, screening, preventive, and rehabilitative services as set out in 42 CFR 440.130; (h) Nursing services; (i) Nurse Practitioner services; (j) Occupational therapy services; (k) Personal care services; (l) Physical therapy services; (m) Physician services; (n) Specialized transportation services; and (o) Speech-language pathology services. (3) Medicaid-covered services provided to children and young adults ages 0-21 are not subject to Oregon’s Medicaid program’s HERC Prioritized List of Health Services. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 38-1999, f. & cert. ef. 10-1-99 HR 22-1995, f. & cert. ef. 12-1-95 HR 39-1991, f. & cert. ef. 9-16-91
410-133-0080 Coverage (1) Services provided or supervised by Medicaid-enrolled SBHS-recognized providers are covered when EPSDT medical necessity and appropriateness are supported by: (a) For planned services: (A) The child or young adult’s IPOC; and (B) The rendering provider’s service documentation. (b) For unplanned services, the rendering provider’s service documentation which must include: (A) Date of service; (B) Medicaid-enrolled child or young adult’s: (i) Full name; (ii) Medicaid ID; and (iii) Diagnosis code(s); (C) Name of the school medical provider; (D) Name of the rendering provider performing the service; (E) Name of the healthcare provider supervising the service (when applicable); (F) Medically necessary and appropriate need for the service; (G) Location and duration of the service; and (H) Nature, extent, or units of service. (2) Specialized transportation services are covered when: (a) The child or young adult requires specialized transportation to serve their individual health-related needs; (b) Specified as a related service in the child or young adult’s IEP or IFSP; (c) Documentation supports specialized transportation is medically necessary and appropriate; (d) A separate school-based health service, other than transportation, specified on the child or young adult’s IEP or IFSP is provided and reimbursed on the same day; and (e) Supported by a transportation vehicle trip log. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020 DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020 DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16 DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03 OMAP 31-2003, f. & cert ef. 4-1-03 OMAP 31-1998, f. & cert. ef. 9-1-98 HR 21-1995, f. & cert. ef. 12-1-95 HR 39-1991, f. & cert. ef. 9-16-91
410-133-0140 Provider Enrollment (1) Enrollment with the Authority is subject to and in compliance with OAR 410-120-1260 and 943-120-0320. (2) Education agencies must be enrolled as a school medical provider with the Authority to bill and receive reimbursement for Medicaid-covered. (3) Supervisory-level rendering providers providing or supervising services in education settings, for which the education agency intends to seek Medicaid reimbursement, must be enrolled with the Authority. (4) Authority-enrolled providers must submit updates to the Authority within thirty (30) calendar days of the change under the EDMS Coversheet (MSC 3970). Changes include address, contact information, NPI, and Federal Tax Identification Number (TIN), when applicable. (5) Authority Medicaid provider enrollment process: (a) For an education agency enrolling as a school medical provider, complete and submit a school medical provider enrollment application including the EDMS Coversheet, all required Oregon Medicaid forms, and the Provider Enrollment Attachment; or (b) For supervisory-level rendering providers, complete and submit a provider enrollment application including the EDMS Coversheet and all required Oregon Medicaid forms. (c) Required forms are unique to each provider and are available on the Oregon Health Plan Provider Enrollment website. (d) The school medical provider may submit completed enrollment forms on behalf of supervisory-level rendering providers that are employed by the school medical provider. (e) Upon submission of a provider enrollment application, the Authority shall: (A) Enroll a school medical provider or supervisory-level rendering provider that has satisfied the provider enrollment criteria; (B) Notify the applicant if information is missing or invalid; or (C) Deny enrollment if Authority provider enrollment criteria are not satisfied. (D) Upon enrollment, notify the contact listed on the provider enrollment application of the enrolled, assigned Medicaid Identification number. (6) Revalidation of Authority-enrolled providers is subject to and in compliance with OAR 410-120-1260. (7) Termination of provider enrollment is subject to and in compliance with OAR 410-120-1260. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03 OMAP 31-1998, f. & cert. ef. 9-1-98 HR 39-1991, f. & cert. ef. 9-16-91
410-133-0200 Services Not Covered (1) Oregon’s School-Based Health Services (SBHS) program does not cover or reimburse for: (a) Services that are not provided and documented by SBHS-recognized providers within their respective scope of practice and in compliance with their respective board rules, OAR 410-120-1360, and OAR 410-133-0120; (b) Unplanned services in lieu of planned services when an IPOC is required by IDEA, Section 504 of the Rehabilitation Act of 1973, or the provider’s scope of practice; (c) Record reviews as a stand-alone service; (d) Meeting preparation; (e) Report writing as a stand-alone service; (f) Correspondence (e.g., copying, mailing, etc.); (g) Purchase of an assistive technology device or software; (h) Activities related to determining Medicaid eligibility and enrollment status, administrative activities, and travel time by SBHS-recognized providers; (i) Educational workshops, training classes, and parent training workshops; (j) Regular transportation services to and from school; (k) Vocational services; (l) Services provided to non-Medicaid children or young adults; (m) Services provided by an entity that employs an excluded provider; or (n) Planned services performed on a date of service for which the child or young adult’s IPOC has lapsed. (2) Education-based costs normally incurred to operate a school and provide an education are not covered for Medicaid reimbursement by the Authority. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03 OMAP 31-2003, f. & cert. ef. 4-1-03 OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00 OMAP 38-1999, f. & cert. ef. 10-1-99 HR 21-1995, f. & cert. ef. 12-1-95 HR 39-1991, f. & cert. ef. 9-16-91