reglab/statecodes huggingface dataset:
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.690 - Prioritized list of health services.

(1) The Health Evidence Review Commission shall regularly solicit testimony and information from stakeholders representing consumers, advocates, providers, carriers and employers in conducting the work of the commission.
(2) The commission shall actively solicit public involvement through a public meeting process to guide health resource allocation decisions.
(3) The commission shall develop and maintain a list of health services ranked by priority, from the most important to the least important, representing the comparative benefits of each service to the population to be served. The list must be submitted by the commission pursuant to subsection (5) of this section and is not subject to alteration by any other state agency.
(4) In order to encourage effective and efficient medical evaluation and treatment, the commission:
(a) May include clinical practice guidelines in its prioritized list of services. The commission shall actively solicit testimony and information from the medical community and the public to build a consensus on clinical practice guidelines developed by the commission.
(b) May include statements of intent in its prioritized list of services. Statements of intent should give direction on coverage decisions where medical codes and clinical practice guidelines cannot convey the intent of the commission.
(c) Shall consider both the clinical effectiveness and cost-effectiveness of health services, including drug therapies, in determining their relative importance using peer-reviewed medical literature as defined in ORS 743A.060.
(5) The commission shall report the prioritized list of services to the Oregon Health Authority for budget determinations by July 1 of each even-numbered year.
(6) The commission shall make its report during each regular session of the Legislative Assembly and shall submit a copy of its report to the Governor, the Speaker of the House of Representatives and the President of the Senate.
(7) The commission may alter the list during the interim only as follows:
(a) To make technical changes to correct errors and omissions;
(b) To accommodate changes due to advancements in medical technology or new data regarding health outcomes;
(c) To accommodate changes to clinical practice guidelines; and
(d) To add statements of intent that clarify the prioritized list.
(8) If a service is deleted or added during an interim and no new funding is required, the commission shall report to the Speaker of the House of Representatives and the President of the Senate. However, if a service to be added requires increased funding to avoid discontinuing another service, the commission shall report to the Emergency Board to request the funding.
(9) The prioritized list of services remains in effect for a two-year period beginning no earlier than October 1 of each odd-numbered year. [2011 c.720 §24]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.694 - Commission review of covered reproductive health services.

The Health Evidence Review Commission shall review the coverage described in ORS 743A.067 (2) and, no later than November 1 of each even-numbered year, report to the interim committees of the Legislative Assembly related to health any recommended changes to the coverage described in ORS 743A.067 (2) based upon the latest clinical research. [2017 c.721 §9]
Note:
414.694 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.695 - Medical technology assessment.

(1) As used in this section and ORS 414.698:
(a) "Medical technology" means medical equipment and devices, medical or surgical procedures and techniques used by health care providers in delivering medical care to individuals, and the organizational or supportive systems within which medical care is delivered.
(b) "Medical technology assessment" means evaluation of the use, clinical effectiveness and cost of a technology in comparison with its alternatives.
(2) The Health Evidence Review Commission shall develop a medical technology assessment process. The Oregon Health Authority shall direct the commission with regard to medical technologies to be assessed and the timing of the assessments.
(3) The commission shall appoint and work with an advisory committee whose members have the appropriate expertise to conduct a medical technology assessment.
(4) The commission shall present its preliminary findings at a public hearing and shall solicit testimony and information from health care consumers. The commission shall give strong consideration to the recommendations of the advisory committee and public testimony in developing its assessment.
(5) To ensure that confidentiality is maintained, identification of a patient or a person licensed to provide health services may not be included with the data submitted under this section, and the commission shall release such data only in aggregate statistical form. All findings and conclusions, interviews, reports, studies, communications and statements procured by or furnished to the commission in connection with obtaining the data necessary to perform its functions is confidential pursuant to ORS 192.338, 192.345 and 192.355. [2011 c.720 §25]
Note:
414.695 to 414.701 were enacted into law by the Legislative Assembly but were not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.698 - Comparative effectiveness of medical technologies.

(1) The Health Evidence Review Commission shall conduct comparative effectiveness research of medical technologies selected in accordance with ORS 414.695. The commission may conduct the research by comprehensive review of the comparative effectiveness research undertaken by recognized state, national or international entities. The commission may consider evidence relating to prescription drugs that is relevant to a medical technology assessment but may not conduct a drug class evidence review or medical technology assessment solely of a prescription drug. The commission shall disseminate the research findings to health care consumers, providers and third-party payers and to other interested stakeholders.
(2) The commission shall develop or identify and shall disseminate evidence-based health care guidelines for use by providers, consumers and purchasers of health care in Oregon.
(3) The Oregon Health Authority shall vigorously pursue health care purchasing strategies that adopt the research findings described in subsection (1) of this section and the evidence-based health care guidelines described in subsection (2) of this section. [2011 c.720 §26]
Note:
See note under 414.695.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.701 - Commission may not rely solely on comparative effectiveness research.

The Health Evidence Review Commission, in ranking health services or developing guidelines under ORS 414.690 or in assessing medical technologies under ORS 414.698, and the Pharmacy and Therapeutics Committee, in considering a recommendation for a drug to be included on any preferred drug list or on the Practitioner-Managed Prescription Drug Plan, may not rely solely on the results of comparative effectiveness research. [2011 c.720 §26a]
Note:
See note under 414.695.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.704 - Advisory committee.

The Health Evidence Review Commission shall consult with an advisory committee in determining priorities for mental health care and chemical dependency. The advisory committee shall include mental health and chemical dependency professionals who provide inpatient and outpatient mental health and chemical dependency care. [Formerly 414.730]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.706 - Persons eligible for medical assistance; rules.

Within available funds and subject to the rules of the Oregon Health Authority, medical assistance shall be provided to an individual who is a resident of this state and who:
(1) Is receiving a category of aid;
(2) Would be eligible for a category of aid but is not receiving a category of aid;
(3) Is required by federal law to be included in the state’s medical assistance program in order for that program to qualify for federal funds; and
(4) Is not described in subsection (3) of this section but for whom federal funding is available under Title XIX or XXI of the Social Security Act. [2003 c.735 §3; 2009 c.867 §37; 2011 c.602 §41; 2013 c.688 §77]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.709 - Adjustment of population of eligible persons in event of insufficient resources prohibited.

If insufficient resources are available during a biennium, the population of eligible persons receiving health services may not be reduced below the population of eligible persons approved and funded in the legislatively adopted budget for the Oregon Health Authority for the biennium. [2003 c.735 §4a; 2009 c.595 §321; 2013 c.688 §78]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [1989 c.836 §3; 1991 c.67 §107; 1991 c.753 §5; 1993 c.815 §17; 1997 c.581 §25; 1999 c.1084 §52; 2005 c.381 §17; 2007 c.70 §195; 2009 c.595 §322; 2009 c.867 §45; 2011 c.720 §145]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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 patient’s quality of life or the quality of life of the patient’s caregiver; and
(B) Palliative care is ordered by the patient’s physician or other primary care provider.
(b) The palliative care services, as determined and provided by an interdisciplinary team, must be provided in the patient’s 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:
414.717 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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:
414.719 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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 patient’s 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 Association’s 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:
414.723 was added to and made a part of ORS chapter 414 by legislative action but was not added to any smaller series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.725

[1989 c.836 §6; 1991 c.753 §8; 2003 c.14 §194; 2003 c.735 §13; 2003 c.794 §277; 2003 c.810 §4; 2005 c.806 §8; 2007 c.458 §1; 2009 c.595 §325; 2009 c.795 §3; 2011 c.602 §26; renumbered 414.651 in 2011]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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:
414.726 was added to and made a part of ORS chapter 414 by legislative action but was not added to any smaller series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [2005 c.806 §4; 2009 c.595 §327; 2011 c.602 §43]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [1989 c.836 §8; 1991 c.753 §9; 2003 c.14 §195; 2009 c.595 §328; 2009 c.827 §18; 2011 c.720 §149]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.737

[2003 c.810 §3; 2007 c.751 §8; 2009 c.595 §§330,331; 2011 c.602 §§27,28; renumbered 414.631 in 2011]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [2003 c.810 §11; 2009 c.595 §336; 2011 c.602 §46]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [Subsection (1) of 2003 Edition enacted as 2003 c.735 §16(1); subsections (2) to (5) of 2003 Edition enacted as 2003 c.735 §16(2) to (5) and 2003 c.810 §12(1) to (4); 2007 c.886 §§1,2; 2009 c.595 §§337,338; 2009 c.886 §§4,5; 2011 c.602 §§47,71; 2015 c.27 §46; 2017 c.718 §8]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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, 414.631 and 414.688 to 414.745 shall not be subject to criminal prosecution, civil liability or professional disciplinary action for failing to provide a service which the Legislative Assembly has not funded or has eliminated from its funding pursuant to ORS 414.735. [1989 c.836 §10; 1991 c.753 §10]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [2009 c.867 §29; 2009 c.828 §54]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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 university’s 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 414.756 by section 18, chapter 2, Oregon Laws 2019, apply to reimbursement paid to the Oregon Health and Science University by the Oregon Health Authority on or after July 1, 2025. See section 19, chapter 2, Oregon Laws 2019. The text that applies to reimbursement paid to the university by the authority on or after July 1, 2025, is set forth for the user’s convenience.
The Oregon Health Authority shall ensure that the Oregon Health and Science University receives net reimbursement of at least 84 percent but no more than 100 percent of the university’s 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.
Note:
414.756 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.760 - Payment for patient centered primary care home and behavioral health home services.

(1) The Oregon Health Authority shall provide reimbursement in the state’s 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 state’s 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:
414.760 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [2023 c.424 §2]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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) "Children’s 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 children’s 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 children’s advocacy center. [2015 c.100 §2; 2019 c.141 §14]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [2023 c.228 §28]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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. [2015 c.362 §6]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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:
414.765 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.766 - Behavioral health treatment; rules.

(1) Notwithstanding ORS 414.065 and 414.690, a coordinated care organization must provide behavioral health services to its members that include but are not limited to all of the following:
(a) For a member who is experiencing a behavioral health crisis:
(A) A behavioral health assessment; and
(B) Services that are medically necessary to transition the member to a lower level of care;
(b) At least the minimum level of services that are medically necessary to treat a member’s underlying behavioral health condition rather than a mere amelioration of current symptoms, such as suicidal ideation or psychosis, as determined in a behavioral health assessment of the member or specified in the member’s care plan;
(c) Treatment of co-occurring behavioral health disorders or medical conditions in a coordinated manner;
(d) Treatment at the least intensive and least restrictive level of care that is safe and effective and meets the needs of the individual’s condition;
(e) For all level of care placement decisions, placement at the level of care consistent with a member’s score or assessment using the relevant level of care placement criteria and guidelines;
(f) If the level of placement described in paragraph (e) of this subsection is not available, placement at the next higher level of care;
(g) Treatment to maintain functioning or prevent deterioration;
(h) Treatment for an appropriate duration based on the individual’s particular needs;
(i) Treatment appropriate to the unique needs of children and adolescents;
(j) Treatment appropriate to the unique needs of older adults;
(k) Treatment that is culturally and linguistically appropriate;
(L) Treatment that is appropriate to the unique needs of gay, lesbian, bisexual and transgender individuals and individuals of any other minority gender identity or sexual orientation;
(m) Coordinated care and case management as defined by the Department of Consumer and Business Services by rule; and
(n) Mental health wellness appointments as prescribed by the Oregon Health Authority by rule.
(2) If there is a disagreement about the level of care required by subsection (1)(e) or (f) of this section, a coordinated care organization shall provide to the behavioral health treatment provider full details of the coordinated care organization’s scoring or assessment, to the extent permitted by the federal Health Insurance Portability and Accountability Act privacy regulations, 45 C.F.R. parts 160 and 164, ORS 192.553 to 192.581 or other state or federal laws limiting the disclosure of health information.
(3) The Oregon Health Authority shall adopt by rule a list of behavioral health services that may not be subject to prior authorization. [2017 c.273 §2; 2021 c.116 §1; 2021 c.629 §4]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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:
414.767 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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 individual’s gender identity and the individual’s 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 organization’s 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. [2023 c.228 §24]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 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 414.065.
(B) Does not include:
(i) The drug, device or service being tested in an approved clinical trial, unless a coordinated care organization would provide or pay for the drug, device or service if provided to a member who is not enrolled in an approved clinical trial;
(ii) Items or services required solely for the provision of the drug, device or service being tested in an approved clinical trial;
(iii) Items or services required solely for the clinically appropriate monitoring of the drug, device or service being tested in an approved clinical trial;
(iv) Items or services that are provided solely to satisfy data collection and analysis needs associated with an approved clinical trial and that are not used in the direct clinical management of the member; or
(v) Items or services customarily provided by a clinical trial sponsor free of charge to any participant in an approved clinical trial.
(2) A coordinated care organization may not discriminate against a member on the basis of the member’s participation in an approved clinical trial by:
(a) Denying the provision of or payment for routine health care; or
(b) Excluding, limiting or imposing additional conditions on the provision of or payment for routine health care furnished in connection with the member’s participation in an approved clinical trial.
(3) A coordinated care organization that provides routine health care to a member enrolled in an approved clinical trial is not, based on the provision of that care, liable for any adverse effects of the approved clinical trial. [2016 c.26 §5]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.772 - Limits on use of step therapy.

(1) As used in this section, "step therapy" means a drug protocol in which the cost of a prescribed drug is reimbursed only if the patient has first tried a specified drug or series of drugs.
(2) A coordinated care organization that requires step therapy shall make easily accessible to any provider who is reimbursed by the organization, directly or through a risk-bearing entity, to provide health services to members of the organization, clear explanations of:
(a) The clinical criteria for each step therapy protocol;
(b) The procedure by which a provider may submit to the organization or risk-bearing entity, the provider’s medical rationale for determining that a particular step therapy protocol is not appropriate for a particular patient based on the patient’s medical condition and history; and
(c) The documentation, if any, that a provider must submit to the organization or risk-bearing entity for the organization or entity to determine the appropriateness of step therapy for a specific patient. [Formerly 414.637]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.773 - Certain conditions on reimbursement of claims for behavioral health services prohibited; assignment of CCO member to primary care provider.

(1) A claim for reimbursement for a behavioral health service or a physical health service provided to a medical assistance recipient may not be denied by the Oregon Health Authority or a coordinated care organization on the basis that the behavioral health service and physical health service were provided on the same day or in the same facility, unless required by state or federal law.
(2) A coordinated care organization may not require prior authorization for specialty behavioral health services provided to a medical assistance recipient at a behavioral health home or a patient centered primary care home unless permitted to do so by the authority.
(3) A coordinated care organization must assign a member of the coordinated care organization to a primary care provider if the member has not selected a primary care provider by the 90th day after enrollment in medical assistance. The coordinated care organization shall provide notice of the assignment to the member and to the primary care provider.
(4) A member may select a different primary care provider at any time.
(5) Subsection (1) of this section does not apply to coordinated care organizations’ payments to providers using a value-based payment arrangement or other alternative payment methodology. [2022 c.37 §10]
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.774 - Payment for private duty nursing services for medically fragile children; rules.

(1) At least once each biennium, the Oregon Health Authority shall conduct a nursing market study for the purpose of determining the appropriate Medicaid reimbursement rates for providers of private duty nursing for medically fragile children.
(2) No later than July 1 each year, the authority shall seek approval from the Centers for Medicare and Medicaid Services to adjust the Medicaid reimbursement rates for providers of private duty nursing for medically fragile children, taking into consideration the results of the most recent study described in subsection (1) of this section and applying a cost-of-living adjustment, as determined on an annual basis by the authority by rule.
(3) As used in this section:
(a) "Medically fragile children" means children who have a health impairment requiring intensive, specialized services on a daily basis and who meet hospital level of care and the clinical criteria as defined by the Department of Human Services and the authority by rule.
(b) "Private duty nursing" has the meaning given that term by the authority by rule. [2022 c.11 §2]
Note:
414.774 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.781 - Fee-for-service reimbursement of co-occurring mental health and substance use disorder treatment services.

The Oregon Health Authority shall reimburse the cost of co-occurring mental health and substance use disorder treatment services paid for on a fee-for-service basis at an enhanced rate based on:
(1) Existing reimbursement codes used for co-occurring disorder treatments;
(2) Clinical complexity; and
(3) The education level of the provider. [2021 c.667 §2]
Note:
414.781 and 414.782 were enacted into law by the Legislative Assembly but were not added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 11 - Juvenile Code, Human Services › Chapter 414 - Medical Assistance › Section 414.782 - Reimbursement to ensure access to addiction treatment statewide.

The Oregon Health Authority, with the advice of stakeholders and the Alcohol and Drug Policy Commission, may establish minimum rates of reimbursement paid by the authority or coordinated care organizations to addiction treatment providers to ensure medical assistance recipients’ access, without delay, to all modalities of addiction treatment within each geographic region of this state. [2021 c.667 §8]
Note:
See note under 414.781.