justicedao/ipfs_state_laws huggingface dataset:
333-022-1090 CareAssist: Client Eligibility Review (1) The Authority must verify a client’s eligibility every six months, but may conduct an eligibility review at any time and as many times as necessary within an eligibility period. (2) The Authority must provide CAREAssist clients with a Client Eligibility Review (CER) form and instructions within 60 days of the expiration of their current eligibility period. (3) A client must submit the CER and any other required documentation within the timeframe established by the Authority in the instructions. A deadline for submitting the CER or requested documentation may be extended at the discretion of the Authority. (4) The Authority shall review a client’s application and supporting documentation and verify the information in accordance with OAR 333-022-1040. (5) The Authority must notify a client in writing whether his or her benefits continue and whether there are any changes. Notification shall include the effective date for the client's new enrollment status. If a client is not found eligible for continued benefits the client shall have a right to a hearing in accordance with ORS 183.415. (6) A CAREAssist client who fails to submit the required renewal documents by the requested deadline shall be placed on a restricted status in accordance with OAR 333-022-1120. If the Authority has not received a complete CER at the end of three months, the client is no longer eligible to receive benefits. The Authority must inform the client that he or she is no longer eligible for benefits because the required information was not submitted, eligibility could not be verified and explain that benefits shall end effective the first day of the following month. An individual may reapply for benefits at any time under OAR 333-022-1030. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 23-2016, f. & cert. ef. 8-2-16 PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1100 CareAssist: Client Reporting Requirements (1) A CAREAssist client is required to notify the Authority within 15 calendar days of any of the following: (a) Receiving notification of changes to premium payments or benefits from his or her insurance company or a benefits administrator; (b) Changes in contact information including address and phone number; or (c) Changes in eligibility for group or individual insurance coverage, whether private or publicly funded. (2) A client’s failure to notify the Authority in accordance with section (1) of this rule may result in a client being terminated from the program in accordance with OAR 333-022-1160. A client who is terminated under this section because the client failed to notify the Authority that his or her insurance plan was cancelled may not be eligible to reapply until the client is enrolled in an insurance plan. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1120 CareAssist: Restricted Status (1) The Authority may place a client on restriction if the client fails to return a complete Client Eligibility Review (CER) by the requested deadline. (2) The effective date and duration of the restriction shall be as follows: (a) Restriction takes effect on the first day of the client’s new eligibility period. (b) The restricted period shall not exceed three consecutive months. If the Authority has not received a complete CER at the end of three months, the client is no longer eligible for benefits and the client will be notified in accordance with OAR 333-022-1090. (3) Ending restriction: (a) Six full months of unrestricted benefits shall be approved if the Authority receives a complete CER before the end of the restricted period and determines the client eligible. (b) The effective date for full benefits shall be the date of receipt of the complete CER. (4) The Authority shall notify a client of the restricted status. The notice must comply with ORS 183.415 and explain: (a) How long the restriction is in effect; (b) How the client can come into compliance and have the restriction lifted; and (c) The consequences of not coming into compliance within the specified time period. (5) If a client is placed on restricted status the Authority may only provide the following benefits to the client: (a) Payment of insurance premiums; and (b) Payment of medications that treat HIV, viral hepatitis and opportunistic infections, as those are described in the CAREAssist restricted formulary, available on the CAREAssist website. (6) Restricted clients are ineligible for assistance with the cost of: (a) Prescriptions not listed on the Restricted Formulary; and (b) All medical services, even when that service continues to be paid by the client’s primary insurance. (7) Restricted clients are required to recertify, as indicated in OAR 333-022-1090. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 23-2016, f. & cert. ef. 8-2-16 PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1130 CareAssist: Incarcerated Applicants or Clients (1) A CAREAssist client who is incarcerated in a state or federal correctional institution is ineligible for CAREAssist and shall be terminated from the program in accordance with OAR 333-022-1160. (2) A CAREAssist client who is incarcerated in a city or county correctional facility may remain enrolled in the program for up to 60 days from the first day of incarceration as long as: (a) The client’s primary insurance coverage is maintained and active; and (b) The client completes recertification in accordance with OAR 333-022-1090 as scheduled. (3) At the Authority’s discretion, incarcerated clients, as described in section (2) may continue to receive CAREAssist benefits for an additional 30 days if the client is expected to be released within those additional 30 days. (4) Pre-release application to CAREAssist. The Authority may accept an application and determine eligibility for an individual who is incarcerated but is expected to be released within 30 days of submitting the application. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1140 CareAssist: Bridge Program (1) The Bridge Program provides limited benefits to an individual whose medical provider has applied for the program on the patient’s behalf. The program provides payment for basic services and medications for an individual who is in the process of applying for CAREAssist and insurance. (2) Bridge Program eligibility. In order to be eligible for the Bridge Program an individual must: (a) Be HIV positive or have AIDS; (b) Reside in Oregon; (c) Have income at or below 550 percent of the FPL; (d) Be in the process of applying for long-term medication assistance programs such as Medicaid, Medicare, or applying to CAREAssist; and (e) Have not previously received Bridge Program benefits or have not been terminated from the CAREAssist program within the past 365 days. (3) To apply for Bridge Program benefits a patient’s medical provider must, on behalf of the patient, submit a form prescribed by the Authority and sign the form attesting that the individual is HIV positive or has AIDS. If the health care provider is licensed outside of Oregon, the Authority may request a copy of the applicant's most current laboratory results. (4) The Authority must notify an applicant whether the patient’s application has been approved or denied, in accordance with ORS 183.415. (5) An individual enrolled in the Bridge Program is not guaranteed to be determined eligible for CAREAssist benefits. (6) The Bridge Program benefits include: (a) Assistance with the cost of a 30-day supply of prescription drugs listed on the CAREAssist formulary and designated as available to Bridge Program participants, only if dispensed by a CAREAssist contract in-network pharmacy. (b) Payment of the costs of medical services and laboratory tests as defined by the list of approved Current Procedural Terminology (CPT) codes noted on the Bridge Program instructions and application forms. (7) The Authority may only pay for an individual’s medical visits or laboratory tests for dates of service that are on or after the individual’s enrollment in the Bridge Program. (8) Individuals enrolled in the Bridge Program must actively participate with an assigned CAREAssist caseworker to assure progress toward a sustainable means of medication access. Failure to do so may result in cancellation of enrollment. At a minimum, the client is expected to submit a full application for ongoing assistance with CAREAssist within the 30 days of Bridge Program enrollment. (9) The Bridge Program is not available to an individual who has primary health insurance coverage. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 51-2022, amend filed 05/02/2022, effective 05/24/2022 PH 23-2016, f. & cert. ef. 8-2-16 PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1145 CareAssist: Uninsured Persons Program (1) The Uninsured Persons Program (UPP) provides full-cost coverage for a limited number of medications and medical services for clients who are ineligible for insurance. (2) In order to be eligible for UPP an individual must: (a) Meet all eligibility requirements outlined in OAR 333-022-1020; and (b) Be ineligible for public and private insurance that meets minimum essential coverage under the federal Affordable Care Act, Public Law 111–148; and (c) Be enrolled in Ryan White community-based HIV Case Management Services. (3) To apply for UPP an individual must comply with OAR 333-022-1030 and an application shall be reviewed by the Authority in accordance with OAR 333-022-1040, as applicable. (4) If the Authority determines that an applicant is eligible for CAREAssist benefits the applicant shall be notified in writing within 10 business days of the Authority’s determination. A client’s notification must describe: (a) The eligibility effective date and end date; (b) Group number and benefits associated with that group; (c) A list of CAREAssist in-network pharmacies; (d) Recertification date and process; and (e) The repercussions of not recertifying. (5) UPP eligibility is for six months. (6) If the Authority determines that an applicant is not eligible for UPP benefits an applicant will be notified in writing in accordance with ORS 183.415. (7) An applicant who is denied may reapply at any time. (8) UPP benefits include: (a) Assistance with the cost of prescription drugs listed on the CAREAssist formulary, when dispensed by a CAREAssist contract in-network pharmacy; (b) Full-cost laboratory and medical visits performed in an out-patient setting. Coverage is limited to allowable CPT codes, as designated by the program. The program may cover the cost of each allowable CPT code up to four times a year. Any additional coverage requires prior authorization initiated by the client’s prescribing physician. (c) Medication therapy management; and (d) Tobacco cessation services. (9) An UPP client must notify the Authority immediately if he or she becomes eligible for insurance or obtains insurance. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 23-2016, f. & cert. ef. 8-2-16 PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1147 CareAssist: Dental Benefits (1) The CAREAssist Dental Program provides assistance with out-of-pocket dental expenses related to a specific dental plan or plans identified by the Authority. (2) Clients are eligible for the CAREAssist Dental Program as long as their primary prescription coverage is not provided by the Oregon Health Plan at the time of application. (3) The Dental Program provides assistance with the cost of: (a) The monthly premium on a dental plan identified by the Authority, paid directly to the insurance carrier or benefits administrator. (b) Out-of-pocket dental expenses for services approved by the identified plan. The plan must cover a portion of the specific procedure before CAREAssist assumes any financial cost. (4) The Dental Program cannot provide assistance with the cost of: (a) Out-of-pocket dental expenses related to any dental plan other than the plan or plans specified by the Authority. (b) Dental services for which the CAREAssist-sponsored dental plan will not pay, either because the service is disallowed or the client has maximized the annual dental benefit, as determined by the dental plan administrator. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 23-2016, f. & cert. ef. 8-2-16
333-022-1150 CareAssist: Client Rights Applicants and clients have the following rights: (1) To receive CAREAssist services free of discrimination based on race, color, sex, gender, ethnicity, national origin, religion, age, class, sexual orientation, physical or mental ability. (2) To be informed about services and options available in the CAREAssist programs for which they may be eligible. (3) To have their CAREAssist records be treated confidentially in accordance with OAR chapter 943, division 14. (4) To have access to a written grievance process posted on the CAREAssist website. (5) To receive language assistance services, including access to translation and interpreter services at no cost if the individual has limited English proficiency. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1160 CareAssist: Termination from CAREAssist (1) The Authority may terminate a client or restrict benefits for any of the following: (a) Failure to continue to meet eligibility requirements; (b) Submitting false, fraudulent or misleading information to the Authority in order to obtain or retain benefits; (c) Placement in a custodial institution, such as a state or federal prison, that is legally obligated to provide medical services; or (d) Failure to notify the Authority of changes in accordance with OAR 333-022-1100. (2) The Authority must provide a notice of termination to a client in writing in accordance with ORS 183.415. (3) An individual who is found to have provided false, fraudulent or misleading information to the Authority may not reapply for CAREAssist benefits for six months following the issuance of a final order of termination and may be required to repay the Authority for benefits provided. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-1170 CareAssist: Hearings A client who has benefits denied, restricted, or terminated has a right to a contested case hearing in accordance with ORS Chapter 183. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 30-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2000 HIV Case Management: Purpose (1) The Oregon HIV Case Management Program provides case management and supportive services, through Ryan White Part B case management agencies, that include but are not limited to client-centered services that ensure timely and coordinated access to primary medical care, medications, treatment adherence counseling and other support services for HIV-positive individuals. (2) Case management and supportive services will be available as long as the Oregon Health Authority (Authority) continues to receive Ryan White Program, Part B funds for this purpose. (3) If insufficient funds are available for case management and supportive services, the Authority may reduce case management services or reduce funding for supportive services. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2010 HIV Case Management: Definitions (1) "Agency" refers to a contracted provider delivering Ryan White funded services. (2) "AIDS" means acquired immunodeficiency syndrome. (3) "Authority" means the Oregon Health Authority. (4) "Family" means all individuals counted by an agency in determining the individual or client’s family size. (5) "Federal Poverty Level" or "FPL" means the annual poverty income guidelines, published by the United States Department of Health and Human Services. (6) "Gross monthly income" means income before taxes or other withholdings. (7) "HIV" means the human immunodeficiency virus, the causative agent of AIDS. (8) "HIV case management service area" means all Oregon counties except Multnomah, Washington, Clackamas, Columbia and Yamhill. (9) "Ryan White Program, Part B" means The Ryan White HIV/AIDS Program authorized and funded under Title XXVI of the Public Health Services Act, as amended by the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87, October 30, 2009). (10) "Ryan White Part B case management services agency" or "agency" means a contractor of the Authority that is responsible for providing case management services and administering supportive services to individuals living with HIV/AIDS in a specific jurisdiction. (11) "Supportive services" means financial assistance that can be authorized on behalf of an individual enrolled in Ryan White Part B case management services. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2020 HIV Case Management: Eligibility To be eligible for the HIV Case Management Program an individual must: (1) Be HIV positive or have AIDS; and (2) Reside in an agency’s jurisdiction within the HIV case management service area, unless another agency agrees to provide services and the Authority authorizes the provision of services by that other agency Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2040 HIV Case Management: Approval or Denial of Enrollment (1) The agency will make a determination as to whether the individual is eligible for case management services within 30 days of receiving all documentation in accordance with OAR 333-022-2030. (2) If the agency determines that an individual cannot be enrolled in the HIV Case Management Program an individual will be notified in accordance with ORS 183.415. (3) An individual who has been denied may reapply at any time. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2050 HIV Case Management: Determination of Service Needs Once enrolled in the HIV Case Management Program, a client must participate in a screening and assessment process with an agency to review his or her needs and resources, for the purpose of developing a plan to address the needs identified. The purpose of this assessment is to identify actions to remove barriers to HIV care and treatment. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2060 HIV Case Management: Client Rights Individuals applying for or clients enrolled in the HIV Case Management Program have the following rights: (1) To receive HIV case management services free of discrimination based on race, color, sex, gender, ethnicity, national origin, religion, age, class, sexual orientation, physical or mental ability. (2) To be informed about services and options available in the HIV Case Management Program. (3) To have HIV case management services and other program records maintained confidentially in accordance with OAR chapter 943, division 14. (4) To have access to a written grievance process provided by the agency. (5) To receive language assistance services including access to translation and interpretation services, at no cost if the individual or client has limited English proficiency, in order to access HIV case management services. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2070 HIV Case Management: Client Responsibilities A client enrolled in the HIV Case Management Program is expected to: (1) Participate in screening, assessment, care plan development and implementation activities; (2) Provide accurate eligibility information at all times; (3) Inform the case manager of changes in address, phone number, income, family size, legal name change, or health insurance coverage within 15 days; (4) Make and keep appointments, or cancel or change an appointment within 24 hours of the scheduled time; and (5) Other responsibilities as designated by the agency. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14
333-022-2080 HIV Case Management: Supportive Services (1) A client enrolled in the HIV Case Management Program may be eligible for supportive services if income is at or below 250 percent of the FPL. (2) Authorization by an agency of supportive services is discretionary and a decision to provide such services will be based on the following factors: (a) The agency is funded to provide the services; (b) The funds are available in the agency budget; (c) The services are allowable per the contract with the Authority; (d) No other payer exists to provide the needed services, with the exception of those that qualify for Veteran’s Administration or Indian Health Services who may still qualify to receive Ryan White services; (e) The client is eligible and currently active in the HIV Case Management Program; and (f) The client's need for the service has been determined by the agency and documented in the client’s file. (3) An agency may authorize supportive services for any of the following: (a) Emergency financial assistance, per agency budget, including but not limited to assistance with short-term medical costs, food, utilities or housing; (b) Housing assistance, including but not limited to short-term assistance to support emergency, temporary or transitional housing; (c) Linguistics services, meaning interpretation and translation services; (d) Medical nutritional therapy provided by a licensed registered dietitian outside of a primary care visit, including the provision of nutritional supplements; (e) Oral health care, including but not limited to diagnostic, preventive, and therapeutic services provided by general dental practitioners, dental specialists, dental hygienists and auxiliaries, and other trained primary care providers; (f) Outpatient substance abuse services, meaning the provision of medical or other treatment or counseling to address substance abuse problems in an outpatient setting, provided by a physician or under the supervision of a physician or other qualified/licensed personnel; (g) Residential substance abuse services, meaning treatment to address substance abuse problems in a residential health service setting, provided by a physician or under the supervision of a physician or other qualified/licensed personnel; (h) Home health care services provided in the home by licensed health care workers such as nurses, and the administration of intravenous and aerosolized treatment, parenteral feeding, diagnostic testing, and other medical therapies; (i) Mental health services meaning psychological and psychiatric treatment and counseling services offered to individuals with a mental illness, conducted in a group or individual setting, and provided by a mental health professional licensed or authorized within the state to render such services; (j) Medical transportation services necessary to access health care services; or (k) Other services funded by the Authority. Statutory/Other Authority: ORS 413.042, 431.250 & 431.830 Statutes/Other Implemented: ORS 431.250 & 431.830 History: PH 29-2014, f. 11-10-14, cert. ef. 12-1-14