justicedao/ipfs_state_laws huggingface dataset:
410-124-0006 Transplant Hospital Requirements And Reimbursement Transplant services shall be reimbursed only when provided in a transplant hospital that meets the Division requirements. (1) Medicare certified transplant facility. (2) Must be an enrolled provider with Oregon Health Authority, Health Systems Division outlined in OAR 410-120-1260. (3) Selection of transplant hospitals by geographic location: If the services are available in the state of Oregon, reimbursement shall not be made to out-of-state transplant hospitals. (4) Out-of-state transplant hospitals shall be considered only if: (a) The type of transplant required is not available in Oregon and/or the type of transplant (for example, liver transplant) is available in Oregon but the Oregon transplant hospital does not provide that type of transplant for all clients or all covered diagnoses, (e.g., pediatric transplants); and (b) An in-state transplant hospital requests the out-of-state transplant referral; and (c) Be cost effective as determined by the Division. For example, if the transplant service is covered by the client's benefit package and the client's primary insurer (i.e., Medicare) requires the use of an out-of-state transplant hospital; or (d) It is a contiguous, out-of-state transplant hospital that has a contract or special agreement for reimbursement with the Division. (5) Professional and other services shall be covered according to administrative rules in the applicable provider guides. (6) Reimbursement for covered transplants and follow-up care for transplant services is as follows: (a) For transplants for fee-for-service clients: (A) Transplant facility services — by contract with the Division; (B) Professional services — at the Division's maximum allowable rates. (b) For emergency services, when no special agreement has been established, the rate shall be: (A) 75% of standard inpatient billed charge; and (B) 50% of standard outpatient billed charge. (c) For clients enrolled in Managed Care Entity (MCE), reimbursement for transplant services shall be by agreement between the MCE and the transplant hospital. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 49-2023, adopt filed 06/30/2023, effective 07/01/2023
410-124-0010 Eligibility for Transplant Services (1) To be eligible for transplant services the client must be enrolled under the following Benefit Packages at the time the transplant services are provided: (a) Oregon Health Plan Plus benefit package (BMH) described in OAR 410-120-1210 (4)(a); (b) State funded Healthier Oregon Population (HOP) described in OAR 410-134-0003(2)(a)(C)(xiii) as of July 1, 2022. (2) Clients covered under the following Benefit Packages do not have coverage for transplants: (a) OHP with Limited Drugs (BMM, BMD) — coverage only for services covered by Medicare; (b) Qualified Medicare Beneficiary (MED) — coverage only for services covered by Medicare; (3) If an individual is not eligible for the Oregon Health Plan Plus benefit package at the time the transplant is performed, but is later made retroactively eligible for the Oregon Health Plan Plus benefit package, the Health Systems Division (Division) shall cover transplant services provided during the period of time the individual is eligible. (4) If a client moves from fee-for-service to a Managed Care Entity (MCE), prior authorization must be obtained from the MCE if required by that MCE. If a client moves out of MCE into another MCE, or into fee-for-service, any prior authorizations approved by the original MCE are void, and prior authorization must again be obtained from the new MCE if prior authorization is required by MCE. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023 DMAP 2-2023, temporary amend filed 01/31/2023, effective 02/01/2023 through 07/30/2023 DMAP 22-2022, minor correction filed 02/16/2022, effective 02/16/2022 OMAP 18-2000, f. 9-28-00, cert. ef. 10-1-00 HR 19-1995, f. 9-28-95, cert. ef. 10-1-95 HR 4-1994, f. & cert. ef. 2-1-94 HR 17-1992, f. & cert. ef. 7-1-92 HR 37-1990, f. 11-6-90, cert. ef. 11-9-90
410-124-0040 Emergency Transplants (1) An Emergency Transplant is one in which medical appropriateness requires that a transplant be performed less than five days after determination of the need for a transplant. (2) Emergency transplants are subject to post transplant review of the client's medical records by the Health Systems Division (Division) or Managed Care Entity (MCE), to determine if the client and the transplant hospital met the criteria in these rules at the time of the transplant. Related charges, including transportation, physician's services, and donor charges shall be covered if payment is approved. The Division shall make payment as described in OAR 410-124 -0006 for covered transplants. MCE shall make payment as described in their contract. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 68-2023, amend filed 08/11/2023, effective 08/11/2023 DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023 DMAP 2-2023, temporary amend filed 01/31/2023, effective 02/01/2023 through 07/30/2023 DMAP 21-2022, minor correction filed 02/16/2022, effective 02/16/2022 OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03 OMAP 18-2000, f. 9-28-00, cert. ef. 10-1-00 HR 4-1994, f. & cert. ef. 2-1-94 HR 22-1990, f. & cert. ef. 7-17-90 HR 8-1990(Temp), f. 3-30-90, cert. ef. 4-1-90
410-125-0000 Determining When the Patient Has Medical Assistance (1) The Medical Card gives the client’s name as listed with the Oregon Health Plan (OHP) and their alpha-numeric prime number. (2) Eligibility may change on a monthly basis. In some instances, eligibility will change during the month. Eligibility should be verified each time services are provided in order to assure that the client is eligible for date(s) of service. For ways to verify client eligibility see General Rule 410-120-1140. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 42-1991, f. & cert. ef. 10-1-91 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0150 AFS 72-1989, f. & cert. ef. 12-1-89 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
410-125-0020 Retroactive Eligibility (1) The Division of Medical Assistance Programs (Division) may pay for services provided to an individual who does not have Medicaid coverage at the time services are provided if the individual is made retroactively eligible for medical assistance and eligibility is extended back to the date services were provided. Contact the local branch concerning possible retroactive eligibility. In some cases, the date of branch contact may be considered the date of application for eligibility. (2) Authorization for payment may be given after the service is provided under limited circumstances. For prior authorization information see OAR 410-125-0124 (Hospital Services Program). Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: 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 39-2008, f. 12-11-08, cert. ef. 1-1-09 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0160 & 410-125-0440 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0160, 461-015-0230 & 461-015-0370 AFS 72-1989, f. & cert. ef. 12-1-90 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
410-125-0030 Hospital Hold (1) A hospital hold is a process which allows an in-state general hospital or an out-of-state contiguous general hospital to assist an individual who is admitted to the hospital for an inpatient hospital stay to secure a date of request when the individual is unable to apply for the Oregon Health Plan due to inpatient hospitalization. (2) The Division of Medical Assistance Programs (Division) will accept hospital holds for inpatient stays. Hospitals must either submit a DMAP 3261 or a hospital generated form to Division within 24 hours of the admission time or the next working day. If a hospital uses its own form, the form must contain all the information found on the DMAP 3261. [ED. NOTE: Forms referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01 OMAP 39-2000, f. 11-14-00, cert. ef. 11-15-00 OMAP 12-2000(Temp), f. 8-16-00, cert. ef. 8-17-00 thru 2-1-01
410-125-0040 Title XIX/Title XXI Clients (1) Title XIX /Title XXI clients are eligible for medical assistance through programs established by the Federal government and for which the State receives federal assistance. Most Title XIX/Title XXI clients are eligible for the Plus or Standard Benefit packages. See the General rules (chapter 410 division 120) for more information on eligibility, benefit package, and covered services. Most Title XIX/Title XXI clients are enrolled in a FCHP, a MHO and a DCO. Some Title XIX clients are Medicare Beneficiaries. (2) The Division of Medical Assistance Programs (Division) contracts with Prepaid Health Plans (PHPs): Fully-Capitated Health Plans (FCHPs), Mental Health Organizations (MHOs), and Dental Care Organizations (DCOs), to provide certain medical, mental health and dental services on a prepaid basis. (a) FCHPs provide a comprehensive package of health care benefits including hospital, physician, laboratory, X-ray and other diagnostic imaging, Medicheck (EPSDT), pharmacy, physical therapy, speech-language therapy, occupational therapy, case management, and other services; (b) MHOs provide mental health services. They can be fully-capitated health plans, community mental health programs, private behavioral organizations or a combination thereof; (c) DCOs provide dental care; (d) If the client is enrolled in a Prepaid Health Plan, the name, address and phone number of the plan will appear on the Medical Care Identification. Always check with the plan listed if there is a question about coverage; (e) PHP clients receive most of their primary care services through the PHP or upon referral from the PHP. In emergency situations, all services may be provided without prior authorization or referral. However, all claims for emergency services must be sent to the prepaid health plan. The hospital must work with the client's prepaid health plan to arrange for billing and payment for emergency and non-emergency services; (f) Division will not reimburse for services that can be provided by the client's PHP and are included in the PHP's contract as covered services. Reimbursement is between the service provider and the PHP. (3) Medicare Clients: Some Title XIX clients also have Medicare coverage. Most Medicare beneficiaries who are also eligible for Medicaid will have the full range of covered benefits for both Medicare and Medicaid. However, a few individuals who are Medicare eligible are eligible for only partial coverage through Medicaid. Refer to the General rules (chapter, 410 division 120) for information on eligibility. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 34-1999, f. & cert. ef. 10-1-99 HR 22-1992, f. 7-31-92, cert. ef. 8-1-92 HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0060 HR 2-1991, f. & cert. ef. 1-4-91 HR 31-1990(Temp), f. & cert. ef. 9-11-90 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0170 & 461-015-0180 AFS 72-1989, f. & cert. ef. 12-1-89 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
410-125-0041 Non-Title XIX/XXI Clients (1) State-funded clients are clients who have not qualified for medical assistance through a federal program but have access to medical benefits through state funded programs. There are two categories of clients who are in State-funded programs. (2) Program General Assistance (GA) clients: Program GA clients are children in foster care, in Services to Children and Families (SCF) custody, who are not eligible for Title XIX/Title XXI programs. They have access to the full range of Medicaid covered services, but payment for services provided may be different from that for Title XIX/Title XXI clients. For additional reimbursement information see the Hospital Services Supplemental Information on the Division of Medical Assistance Programs (Division) web site. (3) Program SF clients: Program SF clients are individuals who are receiving treatment in a state facility, such as Oregon State Hospital, or the Eastern Oregon Training Center. These clients may need to receive hospital care outside the state facility. They are entitled to the full range of Medicaid covered hospital services. These individuals will be referred by the state facility for services. They do not have Medical Care Identification cards. They are not enrolled in a Fully Capitated Health Plan. The state facility from which the client is transferred will contact the hospital regarding billing instructions for these clients. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 34-1999, f. & cert. ef. 10-1-99 HR 5-1994, f. & cert. ef. 2-1-94 HR 36-1993, f. & cert. ef. 12-1-93 HR 22-1993(Temp), f. & cert. ef. 9-1-93 HR 42-1991, f. & cert. ef. 10-1-91
410-125-0045 Coverage and Limitations In general, most medically appropriate services are covered. There are, however, some restrictions and limitations. Please refer to the Division of Medical Assistance Programs’ (Division) General Rules Program for information on general scope of coverage and limitations. Some of the limitations and restrictions that apply to hospital services are: (1) Prior authorization (PA): Some services require PA for the Oregon Health Plan (OHP) Plus Benefit Package check OAR 410-125-0080. (2) Non-covered services: (a) Services that are not medically appropriate, unproven medical efficacy or services that are the responsibility of another Department of Human Services (Department) or Oregon Health Authority (Authority) Division are not covered by the Division of Medical Assistance Programs; (b) Service coverage is based on the Health Evidence Review Commission's (HERC) Prioritized List of Services and the client’s benefit package; (c) See the General Rules Program (chapter 410, division 120) and other program divisions in chapter 410 for a list of not covered services. Further information on covered and non-covered services is found in the Revenue Code section in the Hospital Services Supplemental Information. (3) Limitations on hospital benefit days: Clients have no hospital benefit day limitations for treatment of covered services. (4) Dental services: Clients have dental/denturist services identified as covered on the HERC Prioritized List (OAR 410-141-520). (5) Services provided outside of the hospital's licensed facilities; for example, in the client's home or in a nursing home, are not covered by Division as hospital services. The only exceptions to this are Maternity Case Management services and specific nursing or physician services provided during a ground or air ambulance transport. (6) Dialysis services require a written physician prescription. The prescription must indicate the ICD-10 diagnosis code and must be retained by the provider of dialysis services for the period of time specified in the General Rules Program. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15 DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12 DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00 HR 3-1997, f. 1-31-97, cert. ef. 2-1-97 HR 4-1995, f. & cert. ef. 3-1-95 HR 5-1994, f. & cert. ef. 2-1-94 HR 36-1993, f. & cert. ef. 12-1-93 HR 42-1991, f. & cert. ef. 10-1-91
410-125-0050 Client Copayments Copayments may be required for certain services and/or benefit package(s). See OAR 410-120-1230 for specific details. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 77-2002, f. 12-24-02, cert. ef. 1-1-03
410-125-0086 Prior Authorization for FCHP/MHO Clients Most non-emergent inpatient and outpatient services require prior authorization by a Fully Capitated Health Plan (FCHP) or a Mental Health Organization (MHO). Emergency hospital services must be covered by an FCHP or MHO without regard to prior authorization or the emergency care provider’s contractual relationship with the FCHP or MHO. Emergency hospital services are defined as covered inpatient and outpatient services that are needed to evaluate or stabilize an emergency medical condition. Once a client’s condition is considered stabilized, or a medical screening examination has determined that the client’s medical condition is not emergent, an FCHP or MHO may require prior authorization for hospital admission, follow-up care, or further treatment. Failure to obtain prior authorization from the FCHP or MHO may result in a denial of payment for services. Contact the client’s FCHP or MHO for further information on prior authorization. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01 OMAP 34-1999, f. & cert. ef. 10-1-99 HR 36-1993, f. & cert. ef. 12-1-93 HR 42-1991, f. & cert. ef. 10-1-91
410-125-0095 Hospitals Providing Specialized Inpatient Services (1) Some hospitals provide specific highly specialized in patient services by arrangement with the Division. (2) Reimbursement is made according to the terms of a contract between the Division and the hospital. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860 HR 32-1991(Temp), f. & cert. ef. 7-29-91 HR 28-1991(Temp), f. & cert. ef. 7-1-91 HR 15-1991(Temp), f. & cert. ef. 4-8-91 HR 2-1991, f. & cert. ef. 1-4-91 HR 31-1990(Temp), f. & cert. ef. 9-11-90 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580 AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89 AFS 45-1989, f. & cert. ef. 8-21-89 AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89 AFS 36-1989(Temp), f. & cert. ef. 6-30-89 AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89 AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89 AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88 AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88 AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88 AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88 AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88 AFS 46-1987, f. & cert. ef. 10-1-87 AFS 33-1987(Temp), f. & cert. ef. 7-22-87 AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86 AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86 AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85 AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85 AFS 45-1984, f. & cert. ef. 10-1-84 AFS 1-1984, f. & cert. ef. 1-9-84 AFS 37-1983(Temp), f. & cert. ef. 7-15-83 Renumbered from 461-015-0120(5) AFS 60-1982, f. & cert. ef. 7-1-82 AFS 18-1982(Temp), f. & cert. ef. 3-1-82 AFS 68-1981, f. 9-30-81, cert. ef. 10-1-82 AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80 AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80
410-125-0101 Hospital-Based Nursing Facilities and Medicaid Swing Beds To be eligible to receive reimbursement for hospital-based long-term care nursing facility services or Medicaid swing beds, the hospital must: (1) Have approval from the Centers for Medicare and Medicaid Services (CMS) to furnish skilled nursing facility services as a Medicare hospital swing bed unit, (2) Be enrolled and have a current signed HSD provider agreement, (3) Services must be provided, billed, separate from other hospital services. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 94-2023, amend filed 12/22/2023, effective 01/01/2024 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860 HR 32-1991(Temp), f. & cert. ef. 7-29-91 HR 28-1991(Temp), f. & cert. ef. 7-1-91 HR 15-1991(Temp), f. & cert. ef. 4-8-91 HR 2-1991, f. & cert. ef. 1-4-91 HR 31-1990(Temp), f. & cert. ef. 9-11-90 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580 AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89 AFS 45-1989, f. & cert. ef. 8-21-89 AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89 AFS 36-1989(Temp), f. & cert. ef. 6-30-89 AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89 AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89 AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88 AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88 AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88 AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88 AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88 AFS 46-1987, f. & cert. ef. 10-1-87 AFS 33-1987(Temp), f. & cert. ef. 7-22-87 AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86 AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86 AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85 AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85 AFS 45-1984, f. & cert. ef. 10-1-84 AFS 1-1984, f. & cert. ef. 1-9-84 AFS 37-1983(Temp), f. & cert. ef. 7-15-83 Renumbered from 461-015-0120(5) AFS 60-1982, f. & cert. ef. 7-1-82 AFS 18-1982(Temp), f. & cert. ef. 3-1-82 AFS 68-1981, f. 9-30-81, cert. ef. 10-1-82 AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80 AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80
410-125-0102 Medically Needy Clients (1) The QIO can give prior authorization for non-emergency inpatient services for clients who are in the Medically Needy Program but have not yet met their spend-down. Only Medically Needy Program clients under age 21 and pregnant women have coverage for inpatient services if enrolled in the Medically Needy Program. (2) Prior authorization cannot be granted for outpatient services, which require prior authorization. However, you may contact the Division Medical/ Dental Group once the client has been made eligible and request retroactive authorization. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 42-1991, f. & cert. ef. 10-1-91
410-125-0103 Medicare Clients When Medicare is the primary payer, services provided in the inpatient or out-patient setting do not require prior authorization. However, if the Division is the primary payer because the service is not covered by Medicare; the prior authorization requirements listed in chapter 410 division 125 would apply. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 42-1991, f. & cert. ef. 10-1-91