justicedao/ipfs_state_laws huggingface dataset:
333-004-3040 Agency Responsibilities (1) Agencies must designate at least one and no more than two agency staff person(s) to serve as RH Program Coordinator (RHC). (2) Agencies must notify the Reproductive Health Program (RH Program) within 30 calendar days of a change in address, business affiliation, clinic location or closure, licensure, ownership, certification, billing agents or Federal Tax Identification Number (TIN). Failure to notify the RH Program of a change of Federal Tax Identification Number may result in a sanction. Changes in business affiliation, ownership, and Federal Tax Identification Number may require the submission of a new application. In the event of bankruptcy proceedings, the agency must immediately notify the RH Program in writing. The RH Program may recover payments made to agencies who have not notified the RH Program of changes as required by this section. (3) Agencies must notify the RH Program within 30 calendar days of any changes that will result in noncompliance with certification requirements, such as but not limited to, inability to provide full scope of clinical services, inability to purchase drugs, devices, or supplies, unless the agency has an exception that has been approved by the RH Program. Agencies must work with the RH Program to develop a corrective action plan to resolve any areas of noncompliance. (4) Agencies must notify the RH Program of intent to cease operating RHCare, CCare, or AbortionCare at any clinic certified with the RH Program 30 calendar days before ceasing operations, unless immediate closure is necessary for reasons beyond the agency’s control. If immediate closure is necessary, the agency must notify the RH Program within 10 business days of closure. (5) Agencies are independent contractors and not officers, employees, or agents of the RH Program. (6) Agencies are responsible for training staff on RHCare, CCare, or AbortionCare operations and requirements based on applicable certification within three months of signing the MSA 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 117-2024, amend filed 12/13/2024, effective 01/01/2025 PH 202-2022, amend filed 10/27/2022, effective 10/27/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3050 Agency Termination (1) Agency initiated termination. An agency may terminate certification. To terminate certification, the agency must (a) Submit written notice to the RH Program by secure electronic mail to rh.program@oha.oregon.gov 30 calendar days prior to the termination effective date. (A) The notice shall specify the termination effective date and plans for notifying and referring clients to other certified RHCare, CCare or AbortionCare clinics. This plan shall outline mechanisms used to notify clients and efforts to ensure coordination of care for clients. (B) The termination effective date shall be at least 30 calendar days upon receipt of notice. (b) Termination of agency certification does not terminate any obligations of the agency for dates of services during which the certification was in effect. (2) RH Program initiated termination. (a) The RH Program may terminate agency certification for reasons including, but not limited to: (A) Failure to address compliance findings within 180 calendar days of the date of initial non-compliance notification; (B) No client enrollment or claims activity for 12 months; or (C) Sanctions as described in OAR 333-004-3200 (Grounds for Agency Sanctions; Sanctions). (b) The RH Program will notify an agency that it or its clinic(s)’ certification will be terminated via a written notice by certified mail, return-receipt requested. (c) The termination effective date shall be 30 calendar days from the date the notice was mailed. (d) Agencies that have been terminated due to OAR 333-004-3050(2)(a)(A) or (C) may not apply for certification for two years after termination. (e) Termination notices will follow ORS chapter 183. 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 86-2024, 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
333-004-3060 Purpose of RH Access Fund The RH Access Fund provides coverage to enrollees for a broad range of reproductive health services and supplies. 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 87-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 187-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3080 Reproductive Health Access Fund Excluded Services by Funding Source (1) Title X does not cover: (a) Sterilizations for enrollees assigned female at birth; (b) Treatment for sexually transmitted infections (STIs) not pursuant to a family planning visit; (c) Stand-alone visits for repeat Pap tests not pursuant to a family planning visit; (d) Hysterectomies or abortions; (e) Procedures performed for medical reasons, whether or not the procedure results in preventing or delaying pregnancy or restoring fertility; (f) Human papillomavirus (HPV) vaccinations; or (g) Any other medical service or laboratory test that is not described in OAR 333-004-3070(2) (Reproductive Health Access Fund Covered Services by Funding Source) and whose primary purpose is other than preventing or achieving pregnancy. (2) CCare does not cover: (a) Sterilizations for enrollees assigned female at birth; (b) Treatment for STIs; (c) Preconception or prenatal care, including pregnancy confirmations; (d) Stand-alone visits for repeat Pap tests; (e) Hysterectomies or abortions; (f) Procedures performed for medical reasons, whether or not the procedure results in preventing or delaying pregnancy or restoring fertility; (g) Human papillomavirus (HPV) vaccinations; or (h) Any other medical service or laboratory test that is not described in OAR 333-004-3070(3) (RH Access Fund Covered Services by Funding Source), and whose primary purpose is other than preventing unintended pregnancy. (3) Reproductive Health Equity Act (RHEA) does not cover: (a) Treatment for STIs; (b) Stand-alone visits for repeat Pap tests; (c) Hysterectomies; (d) Human papillomavirus (HPV) vaccinations; (e) Any other medical service or laboratory test that is not described in ORS 743A.067; (f) Mammography services. These services are available through the ScreenWise program (OAR 333-010-0120(2)(a) (Covered Services)); (g) Abortion services not occurring in clinics certified by the Reproductive Health Program (RH Program). These services, for individuals with a household income and size at or below 185 percent of the federal poverty level (FPL), are available under the benefit package for this population in OAR 410-134-0003(2)(c) (Healthier Oregon and Healthier Oregon Cover All Kids Coverage); or (h) Sterilization procedures. These services, for individuals with a household income and size at or below 138 percent of the FPL, are available under the benefit package for this population in OAR 410-134-0003(2)(c) (Healthier Oregon and Healthier Oregon Cover All Kids Coverage). 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 117-2024, amend filed 12/13/2024, effective 01/01/2025 PH 57-2023, amend filed 12/19/2023, effective 12/19/2023 PH 32-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023 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
333-004-3090 Client Eligibility for the RH Access Fund (1) To be considered eligible for the RH Access Fund, an enrollee must meet the eligibility requirements for Title X, CCare, or RHEA. (a) Title X. To qualify for Title X, an enrollee must: (A) Have a household size and personal income at or below 250 percent of the FPL; and (B) Have reproductive capacity. (b) CCare. For an enrollee’s services to be reimbursed using CCare funds, they must meet the eligibility requirements stated in OAR 333-004-3090(1)(a) (Client Eligibility for the RH Access Fund), and: (A) Reside in Oregon as described in OAR 461-120-0010 (Residency Requirements); (B) Provide a valid Social Security Number (SSN) as required by 42 USC 1320b-7; and (C) Be a citizen of the United States, with acceptable proof of citizenship verification and identity; or (D) Hold eligible immigration status with acceptable proof of eligible immigration verification and identity. (c) RHEA. For an enrollee’s services to be reimbursed using RHEA funds, they must meet the eligibility requirements stated in OAR 333-004-3090(1)(a) (Client Eligibility for the RH Access Fund); and (A) Be able to become pregnant; (B) Reside in Oregon as described in OAR 461-120-0010 (Residency Requirements); and (C) Be ineligible for medical assistance because of 8 U.S.C. 1611 or 1612. (2) Eligibility for CCare does not constitute eligibility for any other medical assistance program. 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 88-2024, 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
333-004-3120 Timely Submission of RH Access Fund Claims (1) RH Access Fund claims are processed once a month. To be included in a given month’s processing, an agency must submit a claim to the RH Program via the RH Program’s contracted data and claims processing vendor and the RH Program must receive the claim 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 agency within 12 months of the date of service. Claims older than 12 months submitted by the agency to the RH Program shall not be paid, except when the RH Program has made an error that caused the agency 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) Data not related to payment of the claim may be corrected by the agency at any time after the date of service. (5) Agencies may void claims at any time after the date of service. 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 89-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 189-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3130 Payment for RH Access Fund Claims (1) The RH Program shall make payments to an agency that actually performs the services for enrollees. The exception to this is if an agency contracts with a provider for RH Program-approved services, then the RH Program will make payment to the agency and the agency will disburse payment to the contracted provider. (2) Reimbursement rates for reproductive health and abortion services are set by the RH Program. Claims are reimbursed at the rates in effect on the date of service. Current reimbursement rates are available on the RH Program’s website (www.healthoregon.org/rh). (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. (5) Consistent with OAR 333-004-3150 (RH Access Fund Requirements for Financial, Clinical and Other Records), payment on a claim shall be made only for services that are adequately documented and billed in accordance with OAR 333-004-3110 (RH Access Billing and Claims) and all applicable administrative rules related to the covered services for which the client is eligible. 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 90-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 190-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3140 Use of Funds (1) Final determination of funding source is made by the RH Program based on information recorded in the RH Access Fund eligibility database and claims data submitted by the agency. (2) Use of Title X Funds. Title X funds may only be used for the reimbursement of family planning services and supplies or related preventive services as defined in OAR 333-004-3070(2) (RH Access Fund Covered Services by Funding Source), provided to enrollees as defined in OAR 333-004-3090(1)(a) (Client Eligibility for the RH Access Fund). (3) Use of CCare Funds. CCare funds may only be used for the reimbursement of CCare services, drugs, devices, and supplies as defined in OAR 333-004-3070(3) (RH Access Fund Covered Services by Funding Source) provided to enrollees as defined in OAR 333-004-3090(1)(b) (Client Eligibility for the RH Access Fund). CCare funds may not be used for an enrollee: (a) Who is in the custody of a law enforcement, corrections, or youth detention agency. (b) Who is enrolled in another medical assistance program administered by the Oregon Health Authority (Authority) that provides family planning benefits. (4) Use of RHEA Funds. RHEA funds may only be used for the reimbursement of reproductive health or abortion services as defined in OAR 333-004-3070(4) (RH Access Fund Covered Services by Funding Source), provided to enrollees as defined in OAR 333-004-3090(1)(c) (Client Eligibility for the RH Access Fund). RHEA funds may not be used for an enrollee who is enrolled in a medical assistance program administered by the Authority that provides family planning benefits. (5) Federal funds may not be used for abortion services. (6) To the extent funding is available, the RH Program may provide funding to agencies, on an equitable basis, to assist with covering administrative costs incurred by agencies in adhering to these rules and program requirements. 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 91-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 57-2023, amend filed 12/19/2023, effective 12/19/2023 PH 32-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023 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
333-004-3160 Reproductive Health Access Fund Reviews and Audits (1) A Reproductive Health Program (RH Program) staff person, contractor, or auditor may review enrollment form documents to determine compliance with client eligibility and enrollment requirements. (2) 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 enrollees by an agency in accordance with OAR 333-004-3090 (Client Eligibility for the RH Access Fund); and (b) The services, drugs, devices, or supplies were provided in accordance with RH Program rules. (3) 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. (4) 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 333-004-3200 (Grounds for Agency Sanctions; Sanctions). (5) The RH Program may deny payment or seek recovery of payment if a review or audit determines non-compliance with enrollment requirements. (6) The RH Program shall notify the agency, in writing, of the improper billing findings and subsequent actions to be taken by the agency to correct the identified findings and any sanctions that may be imposed by the RH Program. 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 117-2024, amend filed 12/13/2024, effective 01/01/2025 PH 191-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3170 RH Access Fund Claim Re-determination (1) If an agency 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 180 calendar days from the date of the RH Access Fund 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 agency is responsible for providing the information needed to adjudicate its claim, including relevant health records and evidence-based practice data to support the position being asserted on review. The RH Program may request additional information that it finds relevant to the review. An agency requesting a re-determination review must include the following: (a) The specific service, supply or item being denied, and include all relevant codes 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 agency as part of the re-determination process. (a) The agency 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 agency requesting review that the re-determination request has been denied if: (A) The agency did not submit a timely request; (B) The required information is not provided at the same time the request is submitted; or (C) The agency fails to submit any additional requested information within 14 business days of request. (5) The RH Program’s final decision under this rule is an order in other than a contested case under ORS 183.484 and the procedures in OAR 137-004-0080 through 137-004-0092 (Miscellaneous, Orders in Other Than Contested Case) 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 93-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 192-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021
333-004-3180 Recovery of RH Access Fund Overpayments to Agencies Resulting from Review or Audit (1) When the RH Program determines that an overpayment has been made to an agency, the amount of overpayment is subject to recovery. (a) If the RH Program determines by the random sampling method set forth in OAR 333-004-3160(2) (Review or Audit of RH Access Fund Claims) that there has been an overpayment, an agency may request a 100 percent audit of all billings submitted to the RH Program for reproductive health or abortion services provided during the period in question. (b) If an agency requests a 100 percent audit: (A) The agency is responsible for payment and arrangement; and (B) The audit must be conducted by a certified public accountant who is knowledgeable with the Oregon Administrative Rules covering the payments in question and must be conducted within 120 calendar days of the request to use such audit in lieu of the RH Program's random sample. (2) The amount of the review or audit overpayment to be recovered: (a) Is the entire amount determined by the RH Program or the amount agreed to by the RH Program and the agency; (b) Is not limited to amounts determined by criminal or civil proceedings; and (c) Includes interest charged at allowable state rates. (3) The RH Program shall deliver to an agency by registered or certified mail or in person a request for repayment of the overpayment and the documentation to support the overpayment amount. (4) The overpayment is due and payable 30 calendar days from the date of the decision by the RH Program: (a) An agency may request an additional 30 calendar day grace period from the RH Program. (b) A request for a hearing does not change the date the repayment of the overpayment is due. (5) The RH Program may extend the reimbursement period for an agency or accept an offer of repayment terms from an agency. Any change in reimbursement period or terms must be made in writing by the RH Program. (6) If the agency refuses to reimburse the overpayment or does not adhere to an agreed upon payment schedule, the RH Program may: (a) Recoup future agency payments up to the amount of the overpayment; (b) Suspend or terminate the agency’s certification; or (c) Pursue civil action to recover the overpayment. (7) The RH Program may, at any time, change the amount of the overpayment upon receipt of additional information. The RH Program shall notify an agency in writing of any changes. Any monies paid to the RH Program by an agency that exceed an overpayment shall be refunded to the agency. (8) If an agency is terminated or sanctioned for any reason, the RH Program may pursue civil action to recover any amounts due and payable to the RH Program. 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 94-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 193-2022, minor correction filed 09/07/2022, effective 09/07/2022 PH 84-2020, adopt filed 12/18/2020, effective 01/01/2021