justicedao/ipfs_state_laws huggingface dataset:
ORS Chapter 414 — Medical Assistance

ORS 414.710. Services not subject to prioritized list. The following services are not subject to ORS 414.690: (1) Nursing facilities, institutional and home- and community-based waivered services funded through the Department of Human Services; and (2) Services to children who are wards of the Department of Human Services by order of the juvenile court and services to children and families for health care or mental health care through the department.
ORS Chapter 414 — Medical Assistance

ORS 414.712. Health services for certain eligible persons. The Oregon Health Authority shall provide health services under ORS 414.591, 414.631 and 414.688 to 414.745 to eligible persons who are determined eligible for medical assistance as defined in ORS 414.025. The Oregon Health Authority shall also provide the following: (1) Ombudsman services for individuals who receive medical assistance under ORS 411.706 and for recipients who are members of coordinated care organizations. With the concurrence of the Governor and the Oregon Health Policy Board, the Director of the Oregon Health Authority shall appoint ombudsmen and may terminate an ombudsman. Ombudsmen are under the supervision and control of the director. An ombudsman shall serve as a recipients advocate whenever the recipient or a physician or other medical personnel serving the recipient is reasonably concerned about access to, quality of or limitations on the care being provided by a health care provider or a coordinated care organization. Recipients shall be informed of the availability of an ombudsman. Ombudsmen shall report to the Governor and the Oregon Health Policy Board in writing at least once each quarter. A report shall include a summary of the services that the ombudsman provided during the quarter and the ombudsmans recommendations for improving ombudsman services and access to or quality of care provided to eligible persons by health care providers and coordinated care organizations. (2) Case management services in each health care provider organization or coordinated care organization for those individuals who receive assistance under ORS 411.706. Case managers shall be trained in and shall exhibit skills in communication with and sensitivity to the unique health care needs of individuals who receive assistance under ORS 411.706. Case managers shall be reasonably available to assist recipients served by the organization with the coordination of the recipients health services at the reasonable request of the recipient or a physician or other medical personnel serving the recipient. Recipients shall be informed of the availability of case managers. (3) A mechanism, established by rule, for soliciting consumer opinions and concerns regarding accessibility to and quality of the services of each health care provider. (4) A choice of available medical plans and, within those plans, choice of a primary care provider. (5) Due process procedures for any individual whose request for medical assistance coverage for any treatment or service is denied or is not acted upon with reasonable promptness. These procedures shall include an expedited process for cases in which a recipients medical needs require swift resolution of a dispute. An ombudsman described in subsection (1) of this section may not act as the recipients representative during any grievance or hearing process.
ORS Chapter 414 — Medical Assistance

ORS 414.717. Palliative care program; rules. (1) As used in this section: (a) Interdisciplinary team means a group composed of the following individuals who are trained or certified in palliative care: (A) A case manager who is a registered nurse licensed under ORS 678.010 to 678.410; (B) A medical social worker; and (C) A physician or other primary care provider. (b) Palliative care services includes: (A) Palliative care assessment; (B) Advanced care planning including a discussion regarding completing a POLST; (C) Case management and care coordination provided by a registered nurse in an interdisciplinary team; (D) Pain and symptom management; (E) Mental health and medical social work services; (F) Twenty-four hour clinical telephone support; (G) Spiritual care services; and (H) Other services prescribed by the Oregon Health Authority by rule. (c) POLST has the meaning given that term in ORS 127.663. (d) Residential care facility has the meaning given that term in ORS 443.400. (e) Skilled nursing facility has the meaning given that term in ORS 442.015. (2) The authority shall administer a program to provide palliative care services through coordinated care organizations. The authority shall adopt by rule the eligibility requirements and provider qualifications for the program including but not limited to all of the following: (a) A patient qualifies for palliative care services under the program if the patient: (A) Has been diagnosed with a serious illness with a life-limiting prognosis that negatively impacts the patients quality of life or the quality of life of the patients caregiver; and (B) Palliative care is ordered by the patients physician or other primary care provider. (b) The palliative care services, as determined and provided by an interdisciplinary team, must be provided in the patients choice of residence. (c) A provider of palliative care services under the program and a coordinated care organization shall determine the reimbursement paid for services by mutual agreement. (3) A residential care facility or a skilled nursing facility is not subject to the rules adopted by the authority under subsection (2) of this section in the provision or arrangement of palliative care services for residents of the facilities. [2021 c.462 1] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.719. Housing navigation services and social determinants of health; rules. The Oregon Health Authority shall adopt by rule requirements for coordinated care organizations to provide housing navigation services and address the social determinants of health through care coordination. [2021 c.667 11] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.723. Telemedicine services; rules. (1) As used in this section: (a)(A) Audio only means the use of audio telephone technology, permitting real-time communication between a health care provider and a patient for the purpose of diagnosis, consultation or treatment. (B) Audio only does not include: (i) The use of facsimile, electronic mail or text messages. (ii) The delivery of health services that are customarily delivered by audio telephone technology and customarily not billed as separate services by a health care provider, such as the sharing of laboratory results. (b) Telemedicine means the mode of delivering health services using information and telecommunication technologies to provide consultation and education or to facilitate diagnosis, treatment, care management or self-management of a patients health care. (2) To encourage the efficient use of resources and to promote cost-effective procedures in accordance with ORS 413.011 (1)(L), the Oregon Health Authority shall reimburse the cost of health services delivered using telemedicine, including but not limited to: (a) Health services transmitted via landlines, wireless communications, the Internet and telephone networks; (b) Synchronous or asynchronous transmissions using audio only, video only, audio and video and transmission of data from remote monitoring devices; and (c) Communications between providers or between one or more providers and one or more patients, family members, caregivers or guardians. (3)(a) The authority shall pay the same reimbursement for a health service regardless of whether the service is provided in person or using any permissible telemedicine application or technology. (b) Paragraph (a) of this subsection does not prohibit the use of value-based payment methods, including global budgets or capitated, bundled, risk-based or other value-based payment methods, and does not require that any value-based payment method reimburse telemedicine health services based on an equivalent fee-for-service rate. (4) The authority shall include the costs of telemedicine services in its rate assumptions for payments made to clinics or other providers on a prepaid capitated basis. (5) This section does not require the authority or a coordinated care organization to pay a provider for a service that is not included within the Healthcare Procedure Coding System or the American Medical Associations Current Procedural Terminology codes. (6) The authority shall adopt rules to ensure that coordinated care organizations reimburse the cost of health services delivered using telemedicine, consistent with subsections (2) and (3) of this section. [2021 c.117 2] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.726. Requirement to use certified or qualified health care interpreters; reimbursement; rules. (1) As used in this section: (a) Certified health care interpreter has the meaning given that term in ORS 413.550. (b) Qualified health care interpreter has the meaning given that term in ORS 413.550. (2) The Oregon Health Authority shall adopt rules to ensure that a coordinated care organization, in accordance with ORS 414.572 (2)(e), and any other health care provider that is reimbursed for the cost of health care by the state medical assistance program: (a) Works with a certified health care interpreter or a qualified health care interpreter when interacting with a recipient of medical assistance, or a caregiver of a recipient of medical assistance, who has limited English proficiency or who communicates in signed language; and (b) Is reimbursed for the cost of the certified health care interpreter or qualified health care interpreter. [2021 c.453 6] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.728. Reimbursement of rural hospitals on fee-for-service basis. For services provided on a fee-for-service basis to persons who are entitled to receive medical assistance, the Oregon Health Authority shall reimburse Type A and Type B hospitals and rural critical access hospitals, as described in ORS 442.470 and identified by the Office of Rural Health as rural hospitals, fully for the cost of covered services based on the most recent audited Medicare cost report for Oregon hospitals adjusted to reflect the Medicaid mix of services.
ORS Chapter 414 — Medical Assistance

ORS 414.735. Reduction in scope of health services in event of insufficient resources; approval of Legislative Assembly or Emergency Board; notice to providers. (1) If insufficient resources are available during a contract period: (a) The population of eligible persons determined by law may not be reduced. (b) The reimbursement rate for providers and plans established under the contractual agreement may not be reduced. (2) In the circumstances described in subsection (1) of this section, reimbursement shall be adjusted by reducing the health services for the eligible population by eliminating services in the order of priority recommended by the Health Evidence Review Commission, starting with the least important and progressing toward the most important. (3) The Oregon Health Authority shall obtain the approval of the Legislative Assembly, or the Emergency Board if the Legislative Assembly is not in session, before instituting the reductions. In addition, providers contracting to provide health services under ORS 414.591, 414.631 and 414.688 to 414.745 must be notified at least two weeks prior to any legislative consideration of such reductions. Any reductions made under this section shall take effect no sooner than 60 days following final legislative action approving the reductions. (4) This section does not apply to reductions made by the Legislative Assembly in a legislatively adopted or approved budget.
ORS Chapter 414 — Medical Assistance

ORS 414.742. Payment for mental health drugs. The Oregon Health Authority may not establish capitation rates or global budgets that include payment for mental health drugs. The authority shall reimburse pharmacy providers for mental health drugs only on a fee-for-service payment basis.
ORS Chapter 414 — Medical Assistance

ORS 414.743. Payment to noncontracting hospital by coordinated care organization; rules. (1) Except as provided in subsection (2) of this section, a coordinated care organization that does not have a contract with a hospital to provide inpatient or outpatient hospital services under ORS 414.591, 414.631 and 414.688 to 414.745 must, using Medicare payment methodology, reimburse the noncontracting hospital for services provided to a member of the organization at a rate no less than a percentage of the Medicare reimbursement rate for those services. The percentage of the Medicare reimbursement rate that is used to determine the reimbursement rate under this subsection is equal to four percentage points less than the percentage of Medicare cost used by the Oregon Health Authority in calculating the base hospital capitation payment to the organization, excluding any supplemental payments. (2)(a) If a coordinated care organization does not have a contract with a hospital, and the hospital provides less than 10 percent of the hospital admissions and outpatient hospital services to members of the organization, the percentage of the Medicare reimbursement rate that is used to determine the reimbursement rate under subsection (1) of this section is equal to two percentage points less than the percentage of Medicare cost used by the Oregon Health Authority in calculating the base hospital capitation payment to the organization, excluding any supplemental payments. (b) This subsection is not intended to discourage a coordinated care organization and a hospital from entering into a contract and is intended to apply to hospitals that provide primarily, but not exclusively, specialty and emergency care to members of the organization. (3) A hospital that does not have a contract with a coordinated care organization to provide inpatient or outpatient hospital services under ORS 414.591, 414.631 and 414.688 to 414.745 must accept as payment in full for hospital services the rates described in subsections (1) and (2) of this section. (4) This section does not apply to type A and type B hospitals, as described in ORS 442.470, and rural critical access hospitals, as defined in ORS 442.470. (5) The Oregon Health Authority shall adopt rules to implement and administer this section.
ORS Chapter 414 — Medical Assistance

ORS 414.745. Liability of health care providers and plans. Any health care provider or plan contracting to provide services to the eligible population under ORS 414.591,
ORS Chapter 414 — Medical Assistance

ORS 414.755. Payment for hospital services. The Oregon Health Authority shall establish fee-for-service reimbursement rates for inpatient hospital services provided by hospitals that receive Medicare reimbursement on the basis of diagnostic related groups as follows: (1) For the period from October 1, 2009, through September 30, 2013, at the same rate paid by Medicare on the date of the service. (2) For the period beginning October 1, 2013, at a rate that is 70 percent of the rate paid by Medicare on the date of the service.
ORS Chapter 414 — Medical Assistance

ORS 414.756. Payments to Oregon Health and Science University. The Oregon Health Authority shall ensure that the Oregon Health and Science University receives net reimbursement of at least 87 percent but no more than 100 percent of the universitys costs of providing services that are paid for, in whole or in part, with Medicaid funds. Net reimbursement means all Medicaid payments less any amount that is transferred by the university to the authority. [2017 c.538 41; 2019 c.2 17] Note: The amendments to
ORS Chapter 414 — Medical Assistance

ORS 414.760. Payment for patient centered primary care home and behavioral health home services. (1) The Oregon Health Authority shall provide reimbursement in the states medical assistance program for services provided by patient centered primary care homes and behavioral health homes. If practicable, efforts to align financial incentives to support patient centered primary care homes and behavioral health homes for enrollees in medical assistance programs should be aligned with efforts of the learning collaborative described in ORS 413.259 (3). (2) The authority shall require each coordinated care organization, to the extent practicable, to offer patient centered primary care homes and behavioral health homes that meet the standards established in ORS 414.655. (3) The authority may reimburse patient centered primary care homes and behavioral health homes for interpretive services provided to people in the states medical assistance programs if interpretive services qualify for federal financial participation. (4) The authority shall require patient centered primary care homes and behavioral health homes receiving these reimbursements to report on quality measures described in ORS 413.259 (1)(c). [2009 c.595 1164; 2011 c.602 29; 2015 c.798 15] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.761. Payment for bilateral cochlear implants, hearing aids and hearing assistive technology systems for minors. Notwithstanding ORS 414.065 and 414.690, a coordinated care organization and the Oregon Health Authority shall provide to medical assistance recipients who are 18 years of age or younger the devices and services described in ORS 743A.140 and 743A.141.
ORS Chapter 414 — Medical Assistance

ORS 414.762. Payment for child abuse assessment. (1) As used in this section: (a) Child abuse assessment has the meaning given that term in ORS 418.782. (b) Childrens advocacy center has the meaning given that term in ORS 418.782. (c) Forensic interview has the meaning given that term in ORS 418.782. (2) The Oregon Health Authority shall reimburse a childrens advocacy center for the services the center provides: (a) In conducting a child abuse assessment of a child who is eligible for medical assistance; and (b) That are related to the child abuse assessment including, but not limited to: (A) A forensic interview; and (B) Mental health treatment. (3) The authority shall adopt billing and payment mechanisms to ensure that the reimbursement is proportionate to the scope and intensity of the services provided by the childrens advocacy center.
ORS Chapter 414 — Medical Assistance

ORS 414.763. Payment for dispensing of 12-month supply of prescription contraceptives. (1) As used in this section, prescription contraceptive means a drug or device that requires a prescription and is approved by the United States Food and Drug Administration to prevent pregnancy. (2) In determining the extent of prescription drugs to be provided in medical assistance, in accordance with ORS 414.065, the Oregon Health Authority shall ensure payment for a dispensing of prescription contraceptives, to an individual enrolled in the medical assistance program, that is sufficient to last for a period of 12 calendar months.
ORS Chapter 414 — Medical Assistance

ORS 414.764. Payment for services provided by pharmacy or pharmacist. (1) The Oregon Health Authority may reimburse a pharmacist or pharmacy for any health service: (a) Provided to a medical assistance recipient who is not enrolled in a coordinated care organization or a prepaid managed care health services organization; (b) That is within the lawful scope of practice of a pharmacist; and (c) If the authority determines the service is within the types and extent of health care and services to be provided to medical assistance recipients under ORS 414.065. (2) A coordinated care organization may reimburse a pharmacist or pharmacy for any health service: (a) Provided to a medical assistance recipient who is enrolled in the coordinated care organization or a prepaid managed care health services organization that enters into a clinical pharmacy agreement with the pharmacist or pharmacy; and (b) That is within the lawful scope of practice of a pharmacist.
ORS Chapter 414 — Medical Assistance

ORS 414.765. Periodic surveys of pharmacists regarding costs of dispensing prescription drugs. Every three years, the Oregon Health Authority shall: (1) Conduct a survey of retail pharmacy providers that are enrolled as Medicaid providers in the state medical assistance program to determine the costs of the providers for dispensing prescription drugs; and (2) If the survey indicates a change is needed in the professional dispensing fee reimbursement, submit to the Centers for Medicare and Medicaid Services a request for a state plan amendment to change the professional dispensing fee reimbursement, as provided in 42 C.F.R. 447.518(d). [2023 c.184 1] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.766. Behavioral health treatment; rules. (1) Notwithstanding ORS 414.065 and
ORS Chapter 414 — Medical Assistance

ORS 414.767. Survey of medical assistance recipients regarding experience with behavioral health care and services. The Oregon Health Authority shall contract with a third-party vendor to survey medical assistance recipients about their experiences with behavioral health care and services using a standardized survey tool. [2021 c.667 9] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.769. Payment for gender-affirming treatment; rules. (1) As used in this section, gender-affirming treatment means a procedure, service, drug, device or product that a physical or behavioral health care provider prescribes to treat an individual for incongruence between the individuals gender identity and the individuals sex assignment at birth. (2) Notwithstanding ORS 414.065 and 414.690, medical assistance provided to a member of a coordinated care organization or a medical assistance recipient who is not enrolled in a coordinated care organization shall include gender-affirming treatment. (3) The Oregon Health Authority or a coordinated care organization may not: (a) Deny or limit gender-affirming treatment that is: (A) Medically necessary as determined by the physical or behavioral health care provider who prescribes the treatment; and (B) Prescribed in accordance with accepted standards of care. (b) Deny as a cosmetic service a medically necessary procedure prescribed by a physical or behavioral health care provider as gender-affirming treatment, including but not limited to: (A) Tracheal shave; (B) Hair electrolysis; (C) Facial feminization surgery or other facial gender-affirming treatment; (D) Revisions to prior forms of gender-affirming treatment; and (E) Any combination of gender-affirming treatment procedures. (c) Deny or limit gender-affirming treatment unless a physical or behavioral health care provider with experience prescribing or delivering gender-affirming treatment has first reviewed and approved the denial of or the limitation on the treatment. (4) A coordinated care organization must: (a) Contract with a network of gender-affirming treatment providers that is sufficient in numbers and geographic locations to meet the network adequacy standards prescribed by ORS 414.609 (1); and (b)(A) Ensure that gender-affirming treatment services are accessible to all of the coordinated care organizations members without unreasonable delay; or (B) Ensure that all members have geographical access to non-contracting providers of gender-affirming treatment services without unreasonable delay. (5) The authority shall monitor coordinated care organization compliance with the requirements of this section and may adopt rules necessary to carry out the provisions of this section.
ORS Chapter 414 — Medical Assistance

ORS 414.770. Participants in clinical trials. (1) As used in this section: (a) Approved clinical trial has the meaning given that term in ORS 743A.192. (b) Routine health care: (A) Means the types and extent of health care and services that the Oregon Health Authority requires to be provided in medical assistance in accordance with ORS