justicedao/ipfs_state_laws huggingface dataset:
410-110-0045 Monitoring and Reporting Requirements (1) A grantee shall: (a) Submit grant reports to the Authority on a periodic basis. Grant reports will indicate progress to achieve grant benchmarks and goals and report on the expenditure of grant dollars. Failure to comply with reporting requirements may result in grant suspension or termination; and (b) Report specific data or information, to be determined by the Authority. (2) Grant disbursements are contingent on grantee achieving proposed service delivery levels. Failure to achieve proposed service levels or benchmarks may result in grant reduction or termination. (3) Periodically grantee and the Authority shall jointly review progress. Statutory/Other Authority: ORS 413.225 Statutes/Other Implemented: ORS 413.225, 2015 c. 837 § 34 & 414.231 History: Renumbered from 409-110-0045, DMAP 65-2016, f. & cert. ef. 11-29-16 OHP 15-2016, f. & cert. ef. 11-1-16 OHP 8-2016(Temp), f. & cert. ef. 5-9-16 thru 11-4-16
410-115-0000 Purpose The Purpose of this Chapter 410, Division 115, is to establish uniform standards for the Authority’s administration of Oregon Health Plan (OHP) Bridge (as defined in OAR 410-115-0005 below). The rules set forth below in this Chapter 410, Division 115 apply exclusively to the administration and provision of OHP Bridge. Any rule set forth in this Chapter 410, Division 115 that contradicts or conflicts with any rules of general applicability found in other Divisions included in OAR Chapter 410 are superseded by the rules and provisions in this OAR Chapter 410, Division 115. Statutory/Other Authority: ORS 414.241 & 413.042 Statutes/Other Implemented: ORS 414.241, 413.042, 414.025, 414.65 & 414.706 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0010 Application. (1) The Authority shall conduct the application process for OHP Bridge in accordance with the provisions outlined in OAR 410-200-0110. (2) Consistent with 42 C.F.R. 435.905(b), the Authority must provide assistance to all individuals who apply or want to apply for OHP Bridge (applicants), including without limitation, those applicants who may be of Limited English Proficiency, as well as individuals living with disabilities. (3) Applicants to OHP Bridge may utilize authorized representatives in accordance with OAR 410-200-0111. (4) Applicants to OHP Bridge have the right to receive application and health care system navigation assistance from assisters, navigators, and other individuals certified by the Authority to provide application assistance, in accordance with OAR 410-120-0045. Statutory/Other Authority: ORS 411.400, 411.402, 411.404, 413.042, 414.241, 414.534 & 414.706 Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 413.042, 414.241, 414.534, 414.706, 411.406, 411.439, 413.038, 414.025 & 414.536 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0015 Eligibility and Enrollment. (1) Eligibility requirements for OHP Bridge – Basic Medicaid and OHP Bridge – Basic Health Program are described in OAR 410-200-0437 and in OAR 410-200-0438. (2) Effective start dates for OHP Bridge – Basic Medicaid and OHP Bridge – Basic Health Program coverage are established in OAR 410-200-0115. (3) In the event OHP Bridge coverage is incorrectly terminated or denied due to agency error, coverage shall commence or be reinstated as follows: (a) If incorrectly denied due to agency error, the individual’s enrollment in OHP Bridge and their benefit coverage shall begin on the first day of the month in which benefits may have been effective had the Authority not erred in its initial determination; or (b) If incorrectly terminated due to agency error, the individual’s OHP Bridge coverage shall be reinstated with no gap in coverage. (4) OHP Bridge is not subject to any restricted application and enrollment period. Individuals have the right to apply to OHP Bridge at any time and, if determined eligible by the agency as set forth in this Division, be enrolled in OHP Bridge in accordance with this rule. (5) Applicants who are determined to be ineligible for OHP Bridge have the right to appeal the determination in accordance with OAR Chapter 410, Division 141. If, on appeal, the applicant is determined to be eligible for OHP Bridge, eligibility shall be effective in accordance with section (3)(a) of this rule. (6) Eligibility for OHP Bridge – Basic Health Program is evaluated for renewal every twelve (12) months. (7) Eligibility for OHP Bridge – Basic Medicaid is evaluated for renewal as described in OAR 410-200-0115. Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 414.241, 414.534, 42 CFR 433.138, 433.145-433.148, 435.3-435.4, 435.115-435.119, 435.170, 435.190, 435.222, 435.403, 435.940, 435.1200, 457.80, 457.340, 435.110, 458.350, 435.406-435.407, 435.952, 435.956, 435.1008, 457.320, 457.380, 435.608, 435.610, 435.916-435.917, 435.1205, 447.56, 457.350, 457.360, 457.805 & 600, 45 CFR 155.420 & 435.115 Statutes/Other Implemented: ORS 411.402, 411.404, 45 CFR 155.420, ORS 411.060, 411.095, 411.400, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.241, 414.440, 414.534, 414.536 & 414.706 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0020 Continuity of Health Care The agency shall coordinate eligibility and enrollment between the Oregon Health Authority (Authority), the Department of Human Services (Department), and the Federally Facilitated Marketplace as set forth in OAR 410-200-0110 – Coordinated Eligibility and Enrollment Process with the Department of Human Services and the Federally Facilitated Marketplace. Statutory/Other Authority: ORS 413.042, 414.241 & 42 CFR 600 Statutes/Other Implemented: ORS 413.042 & 414.241 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0025 Grievances and Appeals: Managed Care Entities Obligations; OHP Bridge Program Member Rights. (1) In administering OHP Bridge, Managed Care Entities must comply with the grievance, appeal, and contested case administrative rules set forth in OARs 410-141-3875 through 410-141-3915. (2) OHP Bridge members have the right to file a grievance, appeal an adverse benefit determination, and request a contested case hearing as described in OARs 410-141-3875 through OAR 410-141-3915. Statutory/Other Authority: ORS 413.042, 414.065, 414.241 & 42 CFR 600.335 Statutes/Other Implemented: ORS 413.042, 414.065, 414.241, 414.727 & 42 CFR 600 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0030 OHP Bridge Covered Services. (1) OHP Bridge members shall be eligible for the Oregon Health Plan (OHP) Bridge benefit package. (a) Benefit Package identifier: BRG (b) Coverage for the OHP Bridge benefit package includes: (A) Coverage of the ten (10) essential health benefits described in section 1302(b) of the Affordable Care Act as adopted under 42 CFR 600.405; (B) Covered Services set forth for the Oregon Health Plan and defined in OAR 410-141-3820; and, (C) All other services described in the applicable CCO Contracts. (2) The OHP Bridge benefit package does not include: (a) coverage for long-term care and long-term services and supports. (b) coverage of Health Related Social Needs services defined in OAR 410-120-0000. Statutory/Other Authority: ORS 413.042, 414.241 & 42 CFR 600 Statutes/Other Implemented: ORS 413.042, 414.241 & ORS 414.065 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0035 No Premiums or Copayments. OHP Bridge members are not and shall not be required to pay any premiums, copayments and they do not and shall not have to pay any provider to receive covered services. Statutory/Other Authority: ORS 413.042, 414.065, 414.241, 42 CFR 600.505, 600.510, 600.515, 600.520 & 600.525 Statutes/Other Implemented: ORS 413.042 & 414.241 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0040 Service Authorization. The service authorization provisions for OHP Bridge are described in OAR 410-141-3835. Statutory/Other Authority: ORS 413.042, 414.065, 414.241, 414.615, 414.625, 414.635, 414.651 & 42 CFR 600 Statutes/Other Implemented: ORS 413.042, 414.065, 414.241 & ORS 414.610-414.685 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0045 CCO Administration of OHP Bridge – Basic Health Program; OHP Bridge Enrollment and Choice of CCO. (1) OHP Bridge – Basic Health Program shall be administered by Coordinated Care Organizations (CCOs) pursuant to an OHP Bridge – Basic Health Program CCO Contract entered into by each CCO and the state acting by and through the Authority. (2) The terms and conditions included in the OHP Bridge – Basic Health Program CCO Contract shall comply with all applicable state and federal laws, including, without limitation 42 USC 18051, 42 CFR Part 660, ORS 414.241 and 414.245, and OAR Chapter 410, Division 141. The rules set forth in this Division 115, OAR Chapter 410, Division 141, and the federal regulations set forth in 42 CFR Part 600. (3) Applicants determined by the Authority to be eligible for OHP Bridge – Basic Health Program shall be enrolled in a CCO. Enrollment and disenrollment from a CCO, including choice of CCO, shall be made in accordance with OAR 410-141-3805 and OAR 410-141-3810, except that: (a) Exceptions to mandatory managed care enrollment described in OAR 410-141-3805 (4 – 16) do not apply to OHP Bridge - Basic Health Program; and (b) OHP Bridge Basic Health Program members cannot be disenrolled from the OHP Bridge – Basic Health Program and be covered under the fee-for-service (FFS) delivery system under OAR 410-141-3810. Statutory/Other Authority: ORS 411.402, 411.404, 413.042, 414.241, 414.534, 42 CFR 600 & 600.300 Statutes/Other Implemented: ORS 411.402, 411.404, 414.241, 414.534, ORS 411.400, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 411.447, 414.536 & 414.706 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-115-0050 OHP Bridge - BHP Trust Fund. The Authority shall maintain an OHP Bridge - BHP Trust Fund for the receipt of the federal funds and other non-federal funds the Authority is required to use to pay for the Basic Health Program. Pursuant to 42 CFR 600.705, the Authority does not have the right to use the funds maintained in the BHP Trust for any purpose other than the following: (1) Paying contracted rates to the CCOs for providing OHP Bridge – Basic Health Program covered services to OHP Bridge – Basic Health Program members (including ancillary payments related to CCO or provider (or both) performance incentives, risk management, and similar purposes as set forth in the OHP Bridge – Basic Health Program CCO Contract); (2) Paying the CCOs to provide additional covered services or benefits to OHP Bridge – Basic Health Program members, which may be delivered through a network managed by the Authority or its administrator; (3) Paying health care providers directly for covered services that are not included in the OHP Bridge – Basic Health Program CCO contract(s), but are included in the BRG Benefit Package defined in OAR 410-115-0030; and, (4) Paying health care providers directly to augment amounts paid by CCOs for services delivered to OHP Bridge – Basic Health Program members. Statutory/Other Authority: ORS 413.042, 414.241, 414.245, 42 CFR 600, 600.700, 600.705, 600.710 & 600.715 Statutes/Other Implemented: ORS 413.042, 414.241, 414.245 & ORS 414.065 History: DMAP 94-2024, adopt filed 05/29/2024, effective 06/01/2024
410-120-0003 OHP Standard Benefit Package The OHP Standard benefit package is eliminated effective January 1, 2014. Although references to OHP Standard exist elsewhere in rule, the benefit package currently is not funded and is not offered as a benefit. Those enrolled in OHP Standard are enrolled in other existing benefit packages. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.706 History: DAMP 74-2013, f. 12-31-13, cert. ef. 1-1-14
410-120-0030 Children’s Health Insurance Program (1) The Children’s Health Insurance Program (CHIP) is a federal non-entitlement program. The Oregon Health Authority (Authority), Division of Medical Assistance Program (Division) administers two programs funded under CHIP in accordance with the Oregon Health Plan (OHP) waiver and the CHIP state plan: (a) CHIP: Provides health coverage for uninsured, low-income children who are ineligible for Medicaid; (b) CHIP Pre-natal care expansion program. (2) The General Rules Program (OAR 410-120-0000 et. seq.) and the OHP Program rules (OAR 410-141-3500 et. seq.) applicable to the Medicaid program are also applicable to the Authority’s CHIP program. (3) Children under 19 years of age who meet the income limits, citizenship requirements and eligibility criteria for medical assistance established in OAR chapter 410 through the program acronym OHP-CHP receive the OHP benefit package. (For benefits refer to OAR 410-120-1210.) Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 16-2023, minor correction filed 03/31/2023, effective 03/31/2023 DMAP 23-2014, f. & cert. ef. 4-4-14 DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14 DMAP 67-2013, f. & cert. ef. 12-3-13 DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12 DMAP 19-2012, f. 3-30-12, cert. ef. 4-1-12 DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11 DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11 DMAP 23-2010, f. & cert. ef. 9-1-10 DMAP 23-2010, f. & cert. ef. 9-1-10 DMAP 18-2010, f. 6-23-10, cert. ef. 7-1-10 DMAP 37-2009, f. 12-15-09, cert. ef. 1-1-10 DMAP 29-2009(Temp), f. 9-15-09, cert. ef. 10-1-09 thru 3-25-10 DMAP 14-2008, f. 6-13-08, cert. ef. 7-1-08 DMAP 7-2008(Temp), f. 3-17-08 & cert. ef. 4-1-08 thru 9-15-08
410-120-0035 Public Entity (1) This rule pertains to Centers for Medicare and Medicaid (CMS) regulations for payments to and from Oregon Health Authority (Authority) and public entities. (2) Effective July 1, 2008, unit of government providers responsible by rule or contract for the local match share portion for claims eligible for Federal Financial Participation (FFP) submitted to Medicaid for reimbursement must submit the local match payment prior to the Authority claiming the federal share from CMS: (a) Before the provider submits its claims to the Authority, the provider must transfer funds from allowable sources to the Authority representing the local match share of the total allowable cost for claimed services; (b) Upon receipt of provider’s transfer of the local match share and the Authority receipt of claims in the Medical Management Information System (MMIS) that are reimbursable to the extent of the transferred local match share amount, the Authority will claim FFP from CMS and reimburse the provider for the total reimbursable allowable claimed amount for the services; (c) Transfer of the local match share to the Authority means that the provider certifies that for the purposes of 42 CFR 433.51, the funds it transfers to the Authority for the local match share are public funds that are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds; and that all sources of funds are allowable under 42 CFR 433 Subpart B. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 30-2008, f. 9-12-08, cert. ef. 9-15-08 DMAP 27-2008(Temp), f. 6-13-08, cert. ef. 7-1-08 thru 12-28-08
410-120-0250 Managed Care Entity (1) The Authority provides clients with health services through contracts with a Managed Care Entity (MCE). (2) The MCE is responsible for providing, arranging, and making reimbursement arrangements for covered services as governed by state and federal law, or MCE's contract with the Authority, and the OHP administrative rules governing MCEs (OAR chapter 410, division 141). (3) All MCEs are required to provide benefit coverage pursuant to OAR 410-120-1210 and 410-141-0480 through 410-141-0520; however, authorization criteria may vary between MCEs. It is the providers' responsibility to comply with the MCE's Prior Authorization requirements or other policies necessary for reimbursement from the MCE before providing services to any OHP client enrolled in an MCE. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065, 414.631 & 414.651 History: DMAP 76-2022, minor correction filed 09/30/2022, effective 09/30/2022 DMAP 62-2017, amend filed 12/28/2017, effective 01/01/2018 DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12 OMAP 67-2005, f. 12-21-05, cert. ef. 1-1-06 OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05 OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03
410-120-1190 Medically Needy Benefit Program The Medically Needy Program is eliminated effective February 1, 2003. Although references to this benefit exist elsewhere in rule, the program currently is not funded and is not offered as a benefit. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: OMAP 2-2003, f. 1-31-03, cert. ef. 2-1-03
410-120-1350 Buying-Up (1) Providers are not permitted to bill and accept payment from the Division or a managed care plan for a covered service: (a) When a non-covered service has been provided; and (b) Additional payment is sought or accepted from the Division client. (2) Examples include, but are not limited to, charging the client an additional payment to obtain a gold crown (non covered) instead of the stainless steel crown (covered) or charging an additional client payment to obtain eyeglass frames not on the Division or managed care plan contract. (3) If a client wants to purchase a non-covered service or item, the client must be responsible for full payment. The Division or managed care plan payment for a covered service cannot be credited toward the non-covered service. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 27-2023, minor correction filed 04/27/2023, effective 04/27/2023 OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05 OMAP 10-1999, f. & cert. ef. 4-1-99
410-120-1385 Compliance with Public Meetings Law (1) Advisory committees with the authority to make decisions for, conduct policy research for, or make recommendations on administration or policy related to the medical assistance programs operated by the Authority pursuant to ORS Chapter 414 must comply with provisions of ORS 192.610 to 192.690 — Public Meetings Law. (2) This rule applies to those advisory committees of the medical assistance programs operated under ORS Chapter 414 that are both: (a) Created by state constitution, statutes, administrative rule, order, intergovernmental agreement, or other official act, including direct or delegated authority from the Director of the Authority; and (b) Comprised of at least two committee members who are not employed by a public body. (3) Advisory committees subject to this rule must comply with the following provisions: (a) Meetings shall be open to public attendance unless an executive session is authorized. Committees shall meet in a place accessible to persons with disabilities and, upon request, shall make a good faith effort to provide a sign language interpreter for persons with hearing impairment; (b) Groups shall provide advanced notice of meetings, location, and principal subjects to be discussed. Posting notices on the Web site operated by the Authority or Health System Division (Division) shall be sufficient compliance of the advanced notice requirement. (c) Groups shall take minutes at meetings and make them available to the public upon request to the contact person identified on the public notice; (d) Any meeting that is held through the use of telephone or other electronic communication must be conducted in accordance with the Public Meetings Law. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.227 History: DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023 DMAP 29-2023, minor correction filed 04/27/2023, effective 04/27/2023 OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05 OMAP 62-2001, f. 12-28-01, cert. ef. 1-1-02
410-120-1875 Agency Hearing Representatives (1) Subject to the approval of the Attorney General, an agency officer or employee is authorized to appear (but not make legal argument) on behalf of the Authority in the following classes of hearings: (a) Contested case hearings requested by clients in accordance with OAR 410-120-1860 and 410-130-1865; and (b) Contested case hearings involving Providers in accordance with OAR 410-120-1560 to 410-120-1700. (2) Subject to the approval of the Attorney General, the Authority Audit Manager responsible for the Division of Medical Assistance Programs (Division) audits is authorized to appear (but not make legal argument) on behalf of the Authority in the following classes of hearings: (a) Division Overpayment determinations made in an audit under OAR 943-120-1505 (Provider audit); (b) Division Provider Sanction decisions made in conjunction with or in lieu of an overpayment determination in OAR 943-120-1505 (Provider audit). (3) Legal argument as used in ORS 183.452 and this rule has the same meaning as defined in OAR 137-003-0008(1)(c) and (d) 137-003-0545. (4) When a Authority officer or employee, or the Authority Audit Manager, represents the Authority, the presiding officer will advise such representative of the manner in which objections may be made and matters preserved for appeal. Such advice is of a procedural nature and does not change applicable law on waiver or the duty to make timely objection. Where such objections involve legal argument, the presiding officer will provide reasonable opportunity for the Authority officer or employee, or the Authority Audit Manager, to consult legal counsel and permit such legal counsel to file written legal argument within a reasonable time after the conclusion of the hearing. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05 OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03 OMAP 34-2003, f. & cert. ef. 5-1-03 OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00 HR 8-1996, f. 5-31-96, cert. ef. 6-1-96
410-120-1920 Institutional Reimbursement Changes (1) The Division of Medical Assistance Programs (Division) is required under federal regulations, 42 CFR 447, to submit specific assurances and related information to the Centers for Medicare and Medicaid Services (CMS) whenever it makes a significant change in its methods and standards for setting payment rates for inpatient hospital services or long-term care facilities. (2) A "significant change" is defined as a change in payment rates that affects the general method of payment to all providers of a particular type or is projected to affect total reimbursement for that particular type of provider by six percent or more during the 12 months following the effective date. (3) Federal regulation specifies that a public notice must be published in one of the following: (a) A state register similar to the Federal Register. For the Oregon Health Authority (Authority), the state register is the Oregon Bulletin published by the Secretary of State; (b) The newspaper of widest circulation in each city with a population of 50,000 or more; (c) The newspaper of widest circulation in the state, if there is no city with a population of 50,000 or more; (d) The Authority web site for public notices. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12 OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05 OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03 HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0380 HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0006 AFS 13-1985, f. 3-4-85, ef. 4-1-85