reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0180 - Plan of Care

Current through Register Vol. 63, No. 7, July 1, 2024
A written plan of care must be established and maintained for
				each individual admitted to a hospice program, and the care provided to an
				individual must be in accordance with the plan:
(1) Establishment of Plan. The plan is
			 established by the attending physician, the medical director or physician
			 designee and interdisciplinary group prior to providing care.
(2) Content of Plan. The plan must include an
			 assessment of the individual's needs and identification of the services
			 including the management of discomfort and symptom relief. It must state in
			 detail the scope and frequency of services needed to meet the patient's and
			 family's needs.
(3) Review of Plan.
			 The plan must be reviewed and updated, at intervals specified in the plan, by
			 the attending physician, the medical director or physician designee and
			 interdisciplinary group. These reviews must be documented.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0200 - Interdisciplinary Group

Current through Register Vol. 63, No. 7, July 1, 2024
The hospice must designate an interdisciplinary group or groups
				composed of individuals who provide or supervise the care and services offered
				by the hospice:
(1) Composition of
			 group. The hospice must have an interdisciplinary group or groups composed of
			 or including at least the following individuals who are employees of the
			 hospice, or, in the case of a doctor, be under contract with the hospice:
(a) A doctor of medicine or
			 osteopathy;
(b) A registered
			 nurse;
(c) A social
			 worker;
(d) A pastoral or other
			 counselor.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0220 - Requirements for Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
To be covered, hospice services must meet the following
				requirements:
(1) They must be
			 reasonable and necessary for the palliation or management of the terminal
			 illness as well as related conditions.
(2) The individual must elect hospice care in
			 accordance with OAR 410-142-0100  and a plan of care must be established as set
			 forth in OAR 410-142-0180  before services are provided.
(3) The services must be consistent with the
			 plan of care.
(4) A certification
			 that the individual is terminally ill must be completed as set forth in OAR
			 410-142-0060.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0225 - Signature Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division of Medical Assistance Programs requires practitioners to sign for
			 services they order. This signature shall be handwritten or electronic, (or
			 facsimiles of original written or electronic signatures for terminal illness
			 for hospice) and it must be in the client's medical record.
(2) The ordering practitioner is responsible
			 for the authenticity of the signature.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0240 - Hospice Core Services

Current through Register Vol. 63, No. 7, July 1, 2024
The following services are covered hospice services when
				consistent with the plan of care and must be provided in accordance with
				recognized standards of practice:
(1)
			 Nursing services. The hospice must provide nursing care and services by or
			 under the supervision of a registered nurse:
(a) Nursing services must be directed and
			 staffed to assure that the nursing needs of the patient are met;
(b) Patient care responsibilities of nursing
			 personnel must be specified;
(c)
			 Services must be provided in accordance with recognized standards of
			 practice.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0260 - Hospice Level of Care

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Each day
			 of hospice care is classified into one of five levels of care. The level of
			 care determines the payment for each day of hospice benefit:
(a) Routine Home Care. A routine home care
			 day is a day on which a patient who has elected to receive hospice care is in a
			 place of residence and is not receiving continuous home care;
(b) Continuous Home Care. A continuous home
			 care day is a day on which a patient who has elected to receive hospice care is
			 not in an inpatient facility and receives hospice care consisting predominantly
			 of nursing care on a continuous basis at home. Home health aid or homemaker
			 services or both may also be provided on a continuous basis. Continuous home
			 care is only furnished during brief periods of crisis as necessary to maintain
			 the terminally ill individual at home. Nursing care must be provided by a
			 registered nurse or a licensed practical nurse and a nurse must be providing
			 care for more than half of the period of care. A minimum of eight hours of care
			 must be provided during a 24-hour day, which begins and ends at midnight. When
			 fewer than 8 hours of nursing care are required, the services are covered as
			 routine home care rather than continuous home care;
(c) In-Home Respite Care. An in-home respite
			 care day is a day on which short-term in-home care is provided to the patient
			 only when necessary to relieve the family members or other persons caring for
			 the patient at home. Respite care may be provided only on an occasional basis
			 and may not be reimbursed for more than five consecutive days at a time.
			 In-home respite care will be provided at the level necessary to meet the
			 patient's need, with a minimum of eight hours of care provided in a 24-hour
			 day, which begins and ends at midnight. Home health aide/CNA or homemaker
			 services or both may be utilized for providing in-home respite care;
(d) Inpatient Respite Care. An inpatient
			 respite care day is a day on which short-term inpatient care is provided to the
			 patient only when necessary to relieve the family members or other persons
			 caring for the patient at home. Respite care may be provided only on an
			 occasional basis and may not be reimbursed for more than five consecutive days
			 at a time. Payment for the sixth, and any subsequent days, is to be made at the
			 routine home care rate. Respite care may not be provided when the hospice
			 patient is a nursing home resident;
(e) General Inpatient Care. A general
			 inpatient care day is a day on which a hospice patient receives care in an
			 inpatient facility for pain control, acute or chronic symptom management, or
			 other procedures which cannot be managed or provided in any other
			 setting.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0280 - Recipient Benefits

Current through Register Vol. 63, No. 7, July 1, 2024
An individual who has elected to receive hospice care remains
				entitled to receive other services not included in the hospice benefit. These
				services are subject to the same rules as for non-hospice clients. Typical
				services used that are not covered by the hospice benefit include:
(1) Attending physician care (e.g. office
			 visits, hospital visits, etc.);
(2)
			 Medical transportation;
(3) Any
			 services, drugs or supplies for a condition other than the recipient's terminal
			 illness or a related condition (e.g. broken leg, pre-existing
			 diabetes).
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0290 - Hospice Services in a Nursing Facility

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pursuant to Title XIX, Section 1902 and
			 1905, federal statute prohibits the state from paying nursing facility (NF)
			 providers directly for NF services when their Medicaid residents elect hospice
			 care. In these instances, the Centers for Medicare and Medicaid Services (CMS)
			 require the state to pay the hospice provider the additional amount equal to at
			 least 95% of the per diem rate the state would have paid to the NF for NF
			 services for that client in that facility.
(2) When a client resides in a NF and elects
			 hospice care, the hospice provider and the NF must have a written contract
			 which addresses the provision of hospice care and the method upon which the
			 hospice will pay the NF. The hospice and the NF must maintain a copy of the
			 completed and signed contract on file and it must be available upon request.
(3) Reimbursement when a client
			 resides in a NF and elects hospice care:
(a)
			 In accordance with CMS 4308.2, "when hospice care is furnished to an individual
			 residing in a NF, the state will pay hospice an additional amount on routine
			 home care or continuous home care days to take into account the room and board
			 furnished by the NF. In this context, the term 'room and board' includes
			 performance of personal care services, including assistance in the activities
			 of daily living, in socializing activities, administration of medication,
			 maintaining the cleanliness of a residents' room, and supervision and assisting
			 in the use of durable medical equipment and prescribed therapies," as well as
			 any other services considered under the bundled rate for which the NF is paid
			 pursuant to OAR 411-070.
(b) The
			 hospice shall bill the Division of Medical Assistance Programs (Division)
			 directly for the hospice care provided (under routine home care, Revenue code
			 651, or continuous home care, Revenue code 652) and for the cost of NF services
			 at their usual and customary rate for NF services delivered in that NF for that
			 client;
(c) The Division shall pay
			 the hospice provider for the hospice care provided and not to exceed 100% of
			 the current NF basic, complex medical, pediatric, or special contract rate
			 according to the rate schedule for NF services delivered in that NF for that
			 client;
(d) The hospice provider
			 must reimburse the nursing facility according to their contract and after the
			 hospice receives payment from the Division for that NF for that client; and
(e) Reimbursement for services
			 provided under this rule is available only if the recipient of the services is
			 Medicaid-eligible, hospice-eligible, and been found to need NF care through the
			 Pre-Admission Screening process under OAR 411-070-0040.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0300 - Hospice Reimbursement and Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division recalculates its hospice
			 rates annually. When billing for hospice services, the provider must bill the
			 usual charge or the rate based upon the geographic location in which the care
			 is furnished, whichever is lower. See hospice rates on the Oregon Health
			 Authority (Authority) website at:
http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospice.aspx
.
(2) Rates:
(a) The Division bases its rates on the
			 methodology used in setting Medicare rates, adjusted to disregard cost offsets
			 attributable to Medicare coinsurance amounts;
(b) Under the Medicaid hospice benefit
			 regulations, the Division cannot impose cost sharing for hospice services
			 rendered to Medicaid recipients;
(c) The Division sets rates no lower than the
			 rates used under Part A of Title XVIII of the Social Security Act
			 (Medicare);
(d) The Division uses
			 prospective hospice rates;
(e) The
			 Division makes no retroactive adjustments other than the optional application
			 of the cap on overall payments and the limitation on payments for inpatient
			 care, if applicable.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 142 - HOSPICE SERVICES › Section 410-142-0380 - Death With Dignity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Death
			 with dignity services are defined in the Division of Medical Assistance
			 Programs (DMAP) Medical-Surgical Services and Pharmaceutical Services program
			 rules.
(2) All death with dignity
			 services must be billed directly to DMAP, even if the client is in a prepaid
			 health plan (PHP).
(3) Death with
			 dignity services are not included in the hospice care per diem
			 payment.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 143 - HIV/AIDS PREVENTION SERVICES PROGRAM › Section 410-143-0020 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 143 - HIV/AIDS PREVENTION SERVICES PROGRAM › Section 410-143-0040 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 143 - HIV/AIDS PREVENTION SERVICES PROGRAM › Section 410-143-0060 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0000 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
These rules establish the requirements for participation in the
				Essential Workforce Health Care Program (EWHP). The EWHP is established for
				participating employers to provide health care benefits to the employees of
				their facilities. Oregon Health Authority (Authority) shall provide
				supplemental payments to support the funding of these benefits.
Statutory/Other Authority: ORS
				  410.070 & 413.042
Statutes/Other Implemented: ORS
				  410.070,
				  414.033 & OL 2021 ch.
				  595
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0005 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) "Employee
			 Retirement Income Security Act of 1974 (ERISA)" means the federal law that sets
			 minimum standards for most voluntarily established retirement and health plans
			 in private industry to provide protection for individuals in these
			 plans.
(2) "Essential Workforce
			 Health Care Fund (EWHF)" means a jointly administered employee welfare benefit
			 plan governed by ERISA and applicable law that has been established for the
			 purpose of providing health and related benefits to employees of participating
			 employers and their beneficiaries and under the conditions specified in the
			 EWHF Plan.
(3) "Facility" means a
			 facility that is:
(a) A long-term care
			 facility licensed under ORS
			 441.020;
(b) A residential facility as defined in ORS
			 443.400; or
(c) An in-home care agency licensed under ORS
			 443.315.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0010 - Eligibility

Current through Register Vol. 63, No. 7, July 1, 2024
Requirements for an eligible employer to participate in the
				Essential Workforce Healthcare Program.
(1) Sign a memorandum of understanding with
			 the Oregon Health Authority that specifies how the supplemental payments shall
			 be used;
(2) Agree to participate
			 in evidence-based workforce and quality of care improvements; and
(3) Annually report quality and other
			 metrics.
Statutory/Other Authority: ORS
				  410.070 & 413.042
Statutes/Other Implemented: ORS
				  410.070,
				  414.033 & OL 2021 ch.
				  595
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0020 - Memorandum of Understanding

Current through Register Vol. 63, No. 7, July 1, 2024
All participating employers that receive a supplemental payment
				under this program shall sign a Memorandum of Understanding with the Authority.
				The Memorandum of Understanding shall document the requirements and
				responsibilities for using the supplemental payments to provide health care
				benefits to their employees.
Statutory/Other Authority: ORS
				  410.070 & 413.042
Statutes/Other Implemented: ORS
				  410.070,
				  414.033 & OL 2021 ch.
				  595
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0025 - Use of Supplemental Payments

Current through Register Vol. 63, No. 7, July 1, 2024
Participating employers who receive supplemental payments under
				this program shall use the payments to participate in the Essential Workforce
				Health Care Program.
(1) Payments
			 under Essential Workforce Health Care Program shall be used to provide health
			 care benefits to employees of the participating facilities through the
			 Essential Workforce Health Care Fund (EWHF).
(2) Participating employers use of the
			 supplemental payments are subject to the requirements established by the
			 Essential Workforce Health Care Fund (EWHF).
Statutory/Other Authority: ORS
				  410.070 & 413.042
Statutes/Other Implemented: ORS
				  410.070,
				  414.033 & OL 2021 ch.
				  595
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0030 - Evidence-based Workforce and Quality of Care Improvements

Current through Register Vol. 63, No. 7, July 1, 2024
Participating employers agree to participate in evidence-based
				workforce and quality of care improvements, including all of the requirements
				in this rule.
(1) Workforce input into
			 benefit design;
(2) Quantitative
			 and qualitative reporting on impact of health care benefit on
			 workforce;
(3) Retention strategies
			 for workforce; and
(4) Others as
			 mutually agreed upon by the Authority and participating employers.
Statutory/Other Authority: ORS
				  410.070 & 413.042
Statutes/Other Implemented: ORS
				  410.070,
				  414.033 & OL 2021 ch.
				  595
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0040 - Annual Reporting of Quality Metrics

Current through Register Vol. 63, No. 7, July 1, 2024
(1) EWHF shall annually provide reports on
			 all of the following metrics related to quality health benefits:
(a) Health benefits design, including total
			 premium, employer/employee premium split, deductible, out-of-pocket maximum,
			 co-pays, co-insurance;
(b) Services
			 covered by benefit;
(c) Number of
			 employees and their dependents enrolled in the health benefit;
(d) Network adequacy;
(e) Waiting times for select
			 services;
(f) Other measures of
			 employee health and wellness as mutually agreed upon between the Authority and
			 participating employers;
(g)
			 Narrative description of significant changes from the past year or anticipated
			 future changes;
(h) Workforce
			 retention metrics; and
(i) Equity
			 metrics.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0050 - Supplemental Payments Methodology

Current through Register Vol. 63, No. 7, July 1, 2024
Supplemental payments are determined using the following
				methods:
(1) The aggregate available
			 supplemental payment amount for privately-owned Nursing Facilities (NFs) is
			 calculated for each aggregate Medicaid supplemental payment limit calculation
			 period by taking the difference between the aggregate upper payment limit (UPL)
			 from paragraph (a) of this subsection and the aggregate Medicaid payment from
			 paragraph (b) of this subsection.
(a) The
			 aggregate upper payment limit for privately-owned NFs, as presented in the most
			 recently completed Medicaid NF UPL calculation submitted to CMS, shall be
			 calculated in accordance with the Medicaid UPL provisions codified at Title
			 42 CFR §
										447.272 as follows:
(A) Determine aggregate costs under Medicare
			 cost principles using the most recently filed or settled CMS 2540 skilled
			 nursing facility cost reports for privately-owned NFs.
(B) Determine the per diem cost by dividing
			 the aggregate costs from subparagraph (A) of this paragraph by total days of
			 service associated with the same cost reports.
(C) Extract Medicaid days of service for
			 privately-owned NFs from the state's Medicaid Management Information System
			 (MMIS) for the cost reporting periods associated with the cost reports
			 described in clause (A) of this subparagraph.
(D) Determine aggregate Medicaid costs by
			 multiplying the per diem Medicaid cost from section (B) of this paragraph by
			 Medicaid days of service from section(C) of this section.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 144 - ESSENTIAL WORKFORCE HEALTHCARE PROGRAM › Section 410-144-0060 - Oversight

Current through Register Vol. 63, No. 7, July 1, 2024
All payments authorized for this Program are subject to audit
				at the discretion of the Oregon Health Authority (Authority).
Statutory/Other Authority: ORS
				  410.070 & 413.042
Statutes/Other Implemented: ORS
				  410.070,
				  414.033 & OL 2021 ch.
				  595
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0000 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
As used in this division unless the context requires
				otherwise:
(1) "Board of governors"
			 means the governors of a cooperative program as described in OAR
			 410-145-0020.
(2) "Cooperative
			 program" means a program among two or more health care providers for the
			 purpose of providing heart and kidney transplant services including, but not
			 limited to, the sharing, allocation and referral of physicians, patients,
			 personnel, instructional programs, support services, facilities, medical
			 diagnostic, laboratory or therapeutic services, equipment, devices or supplies,
			 and other services traditionally offered by health care providers.
(3) "Director" means the Director of the
			 Department of Human Services.
(4)
			 "Health care provider" means a hospital, physician or entity, a significant
			 part of whose activities consist of providing hospital or physician services in
			 this state. For purposes of the immunities provided under ORS
			 442.700 to
			 442.760 and
			 646.740, "health care provider"
			 includes any officer, director, trustee, employee, or agent of, or any entity
			 under common ownership and control with, a health care provider.
(5) "Hospital" means a health care facility
			 defined in ORS 442.015(14)(a) to
			 (d) and licensed under ORS
			 441.015 - ORS
			 441.097 and includes community
			 health programs established under ORS
			 430.610 - ORS
			 430.700. In other words, as used
			 in this division the term "hospital" includes health care facilities licensed
			 as hospitals, special inpatient care facilities, skilled and intermediate long
			 term care facilities, and ambulatory surgical centers. It also includes
			 community mental health and developmental disabilities programs established
			 under ORS 430.610 to
			 430.700. It does not include
			 establishments furnishing primarily domiciliary care.
(6) "Order" means a decision issued by the
			 director under OAR 410-145-0010  either approving or denying an application for
			 a cooperative program and includes modification of an original order under OAR
			 410-145-0040(3)(b)  and orders under OAR 410-145-0060(1) and (4).
(7) "Party to a cooperative agreement" or
			 "party" means an entity that enters into the principal agreement to establish a
			 cooperative program and applies for approval under this division and any other
			 entity that, with the approval of the director, becomes a member of the
			 cooperative program.
(8)
			 "Physician" means a physician defined in ORS 677.010(12) and licensed under
			 ORS Chapter 677.
(9) "Urban area"
			 means a Metropolitan Statistical Area as defined by the federal Bureau of the
			 Census.
Stat. Auth.: ORS
				  413.042,
				  442.700 & ORS
				  442.755
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0020 - Board of Governors

Current through Register Vol. 63, No. 7, July 1, 2024
(1) If the
			 director issues an order approving an application for a cooperative program
			 under OAR 410-145-0010, the director shall establish a board of governors to
			 govern the cooperative program. The board of governors shall not constitute,
			 for any purpose, a governmental agency.
(2) The board of governors shall consist of
			 the president or other chief executive officer of each health care provider
			 that is a party to the cooperative program agreement and the director or a
			 designee of the director. The designee shall serve at the pleasure of the
			 director. The designee shall not have any economic or other interest in any of
			 the health care providers associated with the cooperative program.
(3) In governing the cooperative program, the
			 board of governors shall develop policy and approve budgets for the
			 implementation of the cooperative program.
(4) The director or designee of the director
			 may reject any operating or capital budget of the cooperative program upon a
			 finding by the director that the budget is not consistent with the goals listed
			 in OAR 410-145-0010(2)(E)  that the cooperative program is expected to
			 achieve.
Stat. Auth.: ORS
				  413.042,
				  442.720 & ORS
				  442.755
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0030 - Annual Report

Current through Register Vol. 63, No. 7, July 1, 2024
Not later than 60 days following each anniversary date of the
				director's approval of a cooperative program, the board of governors of the
				cooperative program shall deliver four copies of an annual report to the
				director, accompanied by a review fee of $16,000. The report shall specifically
				describe:
(1) How heart and kidney
			 transplant services and related services of the cooperative program are being
			 provided in accordance with the order;
(2) Which of the goals identified in the
			 order are being achieved and to what extent; and
(3) Any substantial changes in the
			 cooperative program.
(4) If the
			 cooperative program does not include both heart and kidney transplant services,
			 the annual report will describe any efforts that have been made by the parties
			 over the previous year to provide for inclusion of both heart and kidney
			 transplants in the cooperative program, and will describe what the parties will
			 do to work towards inclusion of such services in the future. The annual report
			 must describe the ongoing efforts being made and any planned efforts for
			 including both heart and kidney transplant services in the cooperative
			 program.
Stat. Auth.: ORS413.042,
				  442.725 & ORS
				  442.755
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0040 - Review and Evaluation of Annual Report

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The director shall review and evaluate
			 the annual report delivered under OAR 410-145-0030. The director shall:
(a) Determine the extent to which the
			 cooperative program is achieving the goals identified in the order;
(b) Review the activities being conducted to
			 achieve the goals; and
(c)
			 Determine whether each of the activities is still necessary and appropriate to
			 achieve the goals.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0050 - Complaint Procedure

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any person
			 may file a complaint with the director requesting that a specific decision or
			 action of a cooperative program supervised by the director be reversed or
			 modified, or that approval for all or part of the activities permitted by the
			 order be suspended or terminated. The complaint shall allege the reasons for
			 the requested action and shall include any evidence relating to the
			 complaint.
(2) The director on the
			 director's own initiative may at any time request information from the board to
			 governors concerning the activities of the cooperative program to determine
			 whether the cooperative program is in compliance with the order.
Stat. Auth.: ORS
				  413.042,
				  442.735 & ORS
				  442.755
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0060 - Action on Complaints

Current through Register Vol. 63, No. 7, July 1, 2024
(1) During
			 the review of the annual report described in OAR 410-145-0040, after receiving
			 a complaint under 410-145-0050, or on the director's own in initiative, the
			 director may take one or more of the following actions:
(a) If the director determines that a
			 particular decision or action is not in accordance with the order, or that the
			 parties are engaging in anticompetitive activity not permitted by the order,
			 the director may direct the board of governors to identify and implement
			 corrective action to insure compliance with the order or may modify the
			 order.
(b) If the director
			 determines that the coopera-tive program is engaging in unlawful activity not
			 permitted by the order or is not complying with the directive given under
			 subsection (a) of this section, the director may serve on the cooperative
			 program a proposed order directing the cooperative program to:
(A) Conform with the directive under
			 sub-section (a) of this section; or
(B) Cease and desist from engaging in the
			 activity.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0070 - Confidentiality of Information

Current through Register Vol. 63, No. 7, July 1, 2024
(1) If
			 parties to a cooperative program agreement provide the director with written or
			 oral information that is confidential or otherwise protected from disclosure
			 under Oregon law, the disclosures shall not be considered a waiver of any right
			 to protect the information from disclosure in other proceedings.
(2) The parties to a cooperative agreement
			 shall specifically identify to the director any information that meets the
			 requirements of section (1) of this rule, and the director shall considered
			 only information that has been so identified by the parties to be confidential.
			 The director will make the decision as to whether such information is in fact
			 protected from disclosure under Oregon law. The director shall inform the party
			 who submitted the information of any decisions regarding its confidentiality.
			 Information which has been found to be subject to disclosure under Oregon law
			 may be released by the director to any requesting persons subject to the
			 provisions of ORS 192.410 - ORS
			 192.505.
Stat. Auth.: ORS
				  413.042,
				  442.750 & ORS
				  442.755
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 145 - COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING › Section 410-145-0080 - Reconsideration and Judicial Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Orders, modifications of orders, findings and directives issued under OAR
			 410-145-0010, 410-145-0040(3), or 410-145-0060(1)(a)  are subject to
			 reconsideration and stay under the procedures provided in 137-003-0080  through
			 137-003-0092.
(2) Notwithstanding
			 the provisions of ORS
			 183.310(6) and
			 183.480, only a party to a
			 cooperative program agreement or the director shall be entitled to a contested
			 case hearing, reconsideration, or judicial review of an order issued pursuant
			 to ORS 442.700 to ORS
			 442.760.
(3) The director may recover any expenses
			 incurred in the conduct of any hearing under this rule, including hearing
			 officer and court reporter fees and the director's legal expenses, through an
			 assessment on other parties to the hearing.
Stat. Auth.: ORS
				  413.042,
				  442.710, ORS
				  442.730, ORS
				  442.740& ORS
				  442.755
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0000 - Foreword

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Health
			 Systems Division (Division) American Indian/Alaska Native (AI/AN) Oregon
			 Administrative Rules are designed to assist the following providers to prepare
			 claims for services provided to clients with Medical Assistance Program
			 coverage:
(a) Indian Health Service (IHS)
			 facilities; and
(b) Tribal 638
			 facilities, defined as Tribally-operated health care clinics owned or operated
			 by a Tribe or Tribal organization with funding authorized by Title I or Title V
			 of the Indian Self-Determination and Education Assistance Act ( Public Law
			 93-638, as amended), and recognized by the Centers for Medicare and Medicaid
			 Services (CMS) under the 1996 Memorandum of Agreement
			 (MOA);
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0020 - Memorandum of Agreement Reimbursement Methodology

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In 1996, a Memorandum of Agreement (MOA)
			 between the Centers for Medicare and Medicaid Services (CMS) and the Indian
			 Health Service (IHS) established the roles and responsibilities of CMS and IHS
			 regarding the Division's American Indian/Alaska Native (AI/AN) Program
			 individuals. The MOA addresses payment for Medicaid services provided to AI/AN
			 individuals on and after July 11, 1996, through health care facilities owned
			 and operated by AI/AN tribes and tribal organizations, which are funded through
			 Title I or V of the Indian Self-Determination and Education Assistance Act (
			 Public Law 93-638).
(2) The IHS
			 and CMS, pursuant to an agreement with the Office of Management and Budget
			 (OMB), developed an all-inclusive rate to be used for billing directly to and
			 reimbursement by Medicaid. This rate is sometimes referred to as the "OMB,"
			 "IHS," "All-Inclusive" (AIR), "encounter," or "MOA" rate and is referenced
			 throughout these rules as the "IHS rate." The IHS rate is updated and published
			 in the Federal Register each fall:
(a) The
			 rate is retroactive to the first of the year;
(b) The Division automatically processes a
			 retroactive billing adjustment each year to ensure payment of the updated rate.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0021 - American Indian/Alaska Native (AI/AN) Provider Enrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 outlines the Division requirements for Indian Health Service (IHS) and Tribal
			 638 clinics to enroll as American Indian/Alaska Native (AI/AN) providers (refer
			 to OAR 410-120-1260, Provider Enrollment).
(2) An IHS or Tribal 638 clinic that operates
			 a retail pharmacy provides durable medical equipment, prosthetics, orthotics,
			 and supplies (DMEPOS) or provides targeted case management (TCM) services must
			 enroll separately as a pharmacy, DMEPOS, or TCM provider. For specific
			 information, refer to OAR chapter 410, division 121, Pharmaceutical Services
			 program; OAR chapter 410, division 122, DMEPOS program; and OAR chapter 410,
			 division 138, TCM program.
(3) To
			 enroll with the Division as an IHCP, a health center must be one of the
			 following:
(a) An IHS direct health care
			 services facility established, operated, and funded by IHS; or
(b) A Tribally-owned and operated facility
			 funded by Title I or V of the Indian Self Determination and Education
			 Assistance Act ( Public Law 93-638) and is referenced throughout these rules
			 as a "Tribal 638" provider:
(A) A Tribal 638
			 facility that has administrative control, operation, and funding for health
			 programs transferred to AI/AN tribal governments under a Title I contract with
			 IHS;
(B) A Tribal 638 facility that
			 assumes autonomy for the provision of the tribe's own health care services
			 under a Title V compact with IHS.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0040 - ICD-10-CM Diagnosis Codes and CPT/HCPCs Procedure Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division requires diagnosis codes on
			 all claims including those submitted by independent laboratories and portable
			 radiology and including nuclear medicine and diagnostic ultrasound providers. A
			 clinic must always provide the client's diagnosis to ancillary service
			 providers when prescribing services, equipment, and supplies.
(2) The appropriate ICD-10-CM code must be
			 used to identify:
(a) Diagnoses;
(b) Symptoms;
(c) Conditions;
(d) Problems;
(e) Complaints; or
(f) Other reasons for the encounter/visit.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0060 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Some
			 covered services or items require prior authorization (PA) by the Division
			 before the service may be provided or before payment will be made. Refer to
			 Oregon Administrative Rule (OAR) 410-120-1320  Authorization of
			 Payment.
(2) Most Oregon Health
			 Plan (OHP) clients have prepaid health services contracted by the Oregon Health
			 Authority (Authority) through enrollment in a PHP. Refer to OAR 410-120-1140  Verification of Eligibility.
(3) An
			 OHP client who is an American Indian or Alaska Native (AI/AN) with proof of
			 Indian heritage is exempt from mandatory enrollment in a PHP and can request
			 disenrollment from a PHP if automatically enrolled. An AI/AN OHP client may
			 choose to remain in the Medicaid fee-for-service (FFS) delivery system for
			 physical, dental, and behavioral health care, including SUD health care and
			 receive services from an Indian Health Service facility, tribal health clinic
			 or program or urban clinic. Refer to OAR 410-141-0060.
(4) If a client is enrolled in a PHP there
			 may be PA requirements for some services that are provided through the PHP. The
			 IHCP shall contact the PHP prior to providing services to any:
(a) Non-AI/AN OHP clients enrolled in a PHP
			 and with whom the IHCP has a contract to comply with the PHP's PA requirements
			 or other policies necessary for reimbursement from the PHP. The IHCP must
			 contact the client's PHP for specific instructions;
(b) AI/AN OHP client enrolled in a PHP with
			 whom the IHCP does not have a contract to comply with PA requirements in these
			 rules, the General Rules, and applicable Division program rules.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0075 - Client Copayments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) AI/AN
			 clients who are members of a federally recognized Indian Tribe or Tribal
			 Organization and receive Medicaid-covered services rendered through an IHCP are
			 exempt from copayments. Refer to OAR 410-120-1230  Client Copayment.
(2) IHCPs may not charge copayments to
			 eligible non-AI/AN Division clients receiving care at their facility.
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.065
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0080 - Professional Ambulatory Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Professional Ambulatory services provided by IHCP include Medical, Diagnostic,
			 Screening, Dental, Vision, Physical Therapy, Occupational Therapy, Podiatry,
			 Behavioral Health, Substance Use Disorder, Maternity Case Management, Speech,
			 Hearing, and Home Health services.
(2) Providers must use the following
			 guidelines in conjunction with all individual program-specific Division
			 administrative rules to determine service coverage and limitations for OHP
			 clients according to their benefit packages:
(a) American Indian/Alaska Native (AI/AN)
			 Services administrative rules (OAR 410 division 146),
(b) General Rules (OAR 410 division 120);
(c) OHP Administrative Rules (OAR
			 410-141-0480, 410-141-0500, and 410-141-0520), and
(d) The Health Evidence Review Commission's
			 (HERC) Prioritized List of Health Services (List).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0085 - Encounter and Recognized Practitioners

Current through Register Vol. 63, No. 7, July 1, 2024
Encounter and Recognized Practitioners
(1) The Division shall reimburse enrolled
			 AI/AN providers as follows:
(a) For services,
			 items, and supplies that meet the criteria of a valid encounter in sections (5)
			 through (7) of this rule;
(b)
			 Reimbursement is limited to the Division's Medicaid-covered services according
			 to a client's OHP benefit package. These services may include any services
			 included in the State Plan under Title XIX or Title XXI of the Social Security
			 Act and provided pursuant to the determinations, conditions, and requirements
			 of the Prioritized List of Health Services found in the Health Evidence Review
			 Commission's Prioritized List of Health Services (see OAR
			 410-141-0520).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0086 - Multiple Encounters

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An
			 "encounter" has the meaning given that term in OAR 410-146-0085.
(2) The following services may be considered
			 as multiple encounters when two or more service encounters are provided on the
			 same date of service with distinctly different diagnoses:
(a) Medical (section (3) of this rule and OAR
			 chapter 410, division 130);
(b)
			 Dental (OAR 410-146-0380  and chapter 410, division 123);
(c) Behavioral Health. If a client is also
			 seen for a medical office visit and receives a behavioral health diagnosis,
			 then the client contacts are a single encounter.
(d) Substance Use Disorder. If a client is
			 also seen for a medical office visit and receives an addiction diagnosis, then
			 the client's contacts are a single encounter (refer to the Division for the
			 appropriate OARs);
(e)
			 Ophthalmology. Fitting and dispensing of eyeglasses are included in the
			 encounter when the practitioner performs a vision examination. (OAR chapter
			 410, division 140);
(f) Maternity
			 Case Management (MCM) (OAR 410-146-0120);
(g) Physical or occupational therapy (PT/OT).
			 If this service is also performed on the same date of service as the medical
			 encounter that determined the need for PT/OT (initial referral), then it is
			 considered a single encounter (OAR chapter 410, division 131);
(h) Immunizations. If no other medical office
			 visit occurs on the same date of service; and
(i) Tobacco cessation. If no other medical,
			 dental, behavioral health, or SUD service encounter occurs on the same date of
			 service (OAR 410-130-0190).
(j) One
			 or more prescriptions for pharmaceuticals and biologicals not generally
			 provided during the clinic visit that are dispensed by an IHS or Tribal 638
			 Pharmacy to the same individual constitute multiple encounters when delivered
			 in a single 24-hour period ending at midnight.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0100 - Vaccines for Children

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Vaccines for Children (VFC) program supplies federally purchased free vaccines
			 for immunizing eligible clients ages 0 through 18 at no cost to participating
			 health care providers. For more information on how to enroll in the VFC
			 program, contact the Oregon Health Authority (Authority) Immunization program.
			 Refer to the AI/AN Supplemental Information for instructions and OAR
			 410-130-0255(4)  VFC program.
(2)
			 The Division shall reimburse for the administration of vaccines to eligible
			 clients according to the IHCP's IHS or cost-based rate.
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.065
Statutes/Other Implemented: ORS
				  414.065