Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1160 - Medical Assistance Benefits and Provider Rules

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Providers enrolled with and seeking
			 reimbursement for services through the Health Systems Division (Division) are
			 responsible for compliance with current federal and state laws and regulations
			 governing Medicaid services and reimbursement, including familiarity with
			 periodic law and rule changes. The Division's administrative rules are posted
			 on the Oregon Health Authority (Authority) website for the Division and its
			 medical assistance programs. It is the provider's responsibility to become
			 familiar with and abide by these rules.
(2) The following services are covered to the
			 extent included in the Division client's benefit package of health care
			 services, when medically or dentally appropriate and within the limitations
			 established by the Division and set forth in the Oregon Administrative Rules
			 (OARs) for each category of Health Services:
(a) Acupuncture services as described in the
			 Medical-Surgical Services program provider rules (OAR chapter 410, division
			 130);
(b) Administrative
			 examinations as described in the Administrative Examinations and Billing
			 Services program provider rules (OAR chapter 410, division 150);
(c) Substance Use Disorder treatment
			 services:
(A) The Division covers Substance
			 Use Disorder (SUD) inpatient treatment services for medically managed intensive
			 inpatient detoxification when provided in an acute care hospital and when
			 hospitalization is considered medically appropriate. The Division covers
			 medically monitored detoxification and clinically managed detoxification
			 provided in a free standing detoxification center or an appropriately licensed
			 SUDs residential treatment facility when considered medically
			 appropriate;
(B) The Division
			 covers non-hospital SUD treatment and recovery services on a residential or
			 outpatient basis. For information to access these services, contact the
			 client's PHP or CCO if enrolled, the Community Mental Health Program (CMHP), an
			 outpatient substance use disorder treatment provider, the residential treatment
			 program, or the Addictions and Mental Health Division (AMH);
(C) The Division does not cover residential
			 level of care provided in an inpatient hospital setting for substance use
			 disorder treatment and recovery;
(d) Ambulatory surgical center services as
			 described in the Medical-Surgical Services program provider rules (OAR 410,
			 division 130);
(e) Anesthesia
			 services as described in the Medical-Surgical Services program provider rules
			 (OAR chapter 410, division 130);
(f) Audiology services as described in the
			 Speech-Language Pathology, Audiology and Hearing Aid Services program provider
			 rules (OAR chapter 410, division 129);
(g) Chiropractic services as described in the
			 Medical-Surgical Services program provider rules (OAR chapter 410, division
			 130);
(h) Clinical trials as
			 described in these General Rules:
(A) Coverage
			 includes routine patient costs for a beneficiary participating in a qualifying
			 clinical trial or any item or service provided to the individual under the
			 qualifying clinical trial, including any item or service provided to prevent,
			 diagnose, monitor, or treat complications resulting from participation in the
			 qualifying clinical trial, to the extent that the items or services to the
			 beneficiary are covered in the recipient's benefit package;
(B) "Qualifying clinical trial" is defined as
			 a clinical trial in any clinical phase of development that is conducted in
			 relation to the prevention, detection, or treatment of any serious or
			 life-threatening disease or condition as described in section 1905(gg)(2)(A) of
			 the Act;
(C) A qualifying clinical
			 trial is a study or investigation that is approved, conducted, or supported
			 (including by funding through in-kind contributions) by one or more of the
			 following:
(i) The National Institutes of
			 Health (NIH);
(ii) The Centers for
			 Disease Control and Prevention (CDC);
(iii) The Agency for Health Care Research and
			 Quality (AHRQ);
(iv) The Centers
			 for Medicare & Medicaid Services (CMS);
(v) A cooperative group or center of any of
			 the entities described above or the Department of Defense or the Department of
			 Veterans Affairs;
(vi) A qualified
			 non-governmental research entity identified in the guidelines issued by the NIH
			 for center support grants;
(vii) A
			 clinical trial, approved or funded by any of the following entities, that has
			 been reviewed and approved through a system of peer review that the Secretary
			 determines comparable to the system of peer review of studies and
			 investigations used by the NIH, and that assures unbiased review of the highest
			 scientific standards by qualified individuals with no interest in the outcome
			 of the review:
(I) The Department of
			 Energy;
(II) The Department of
			 Veterans Affairs;
(III) The
			 Department of Defense;
(viii) A clinical trial that is one conducted
			 pursuant to an investigational new drug exemption under section 505(i) of the
			 Federal Food, Drug, and Cosmetic Act or an exemption for a biological product
			 undergoing investigation under section 351(a)(3) of the Public Health Service
			 Act; or
(ix) A clinical trial that
			 is a drug trial exempt from being required to have one of the exemptions in the
			 prior bullet.
(D) Items
			 and Services not included in clinical trial:
(i) Routine patient costs do not include any
			 investigational item or service that is the subject of the qualifying clinical
			 trial but is not included in the recipient's OHP benefit package;
(ii) Routine patient cost does not include
			 any item or service that is provided to the beneficiary solely to satisfy data
			 collection and analysis for the qualifying clinical trial that is not used in
			 the direct clinical management of the beneficiary and is not otherwise in the
			 recipients OHP benefit package.
(i) Dental services as described in the
			 Dental Services program provider rules (OAR chapter 410, division
			 123);
(j) Early and Periodic
			 Screening, Diagnosis, and Treatment services (EPSDT) are covered for
			 individuals under 21 years of age as set forth in the individual program
			 provider rules. The Division may authorize services in excess of limitations
			 established in the OARs when it is medically appropriate to treat a condition
			 that is identified as the result of an EPSDT screening;
(k) Family planning services as described in
			 the Medical-Surgical Services program provider rules (OAR chapter 410, division
			 130);
(l) Federally qualified health
			 centers and rural health clinics as described in the Federally Qualified Health
			 Centers and Rural Health Clinics program provider rules (OAR chapter 410,
			 division 147);
(m) Home and
			 community-based waiver services as described in the Authority and the
			 Department's OARs of Child Welfare (CW), Self-Sufficiency Program (SSP),
			 Addictions and Mental Health Division (AMH), and Aging and People with
			 Disabilities Division (APD);
(n)
			 Home enteral/parenteral nutrition and IV services as described in the Home
			 Enteral/Parenteral Nutrition and IV Services program rules (OAR chapter 410,
			 division 148) and related Durable Medical Equipment. Prosthetics, Orthotics and
			 Supplies program rules (OAR chapter 410, division 122) and Pharmaceutical
			 Services program rules (OAR chapter 410, division 121);
(o) Home health services as described in the
			 Home Health Services program rules (OAR chapter 410, division 127);
(p) Hospice services as described in the
			 Hospice Services program rules (OAR chapter 410, division 142);
(q) HRSN Services as described in the HRSN
			 Services program rules (OAR 410-120-2000);
(r) Indian health services or tribal facility
			 as described in The Indian Health Care Improvement Act and its amendments
			 (Public Law
			 102-573), and the Division's American
			 Indian/Alaska Native program rules (OAR chapter 410, division 146);
(s) Inpatient hospital services as described
			 in the Hospital Services program rules (OAR chapter 410, division
			 125);
(t) Laboratory services as
			 described in the Hospital Services program rules (OAR chapter 410, division
			 125) and the Medical-Surgical Services program rules (OAR chapter 410, division
			 130);
(u) Licensed direct-entry
			 midwife services as described in the Medical-Surgical Services program rules
			 (OAR chapter 410, division 130);
(v) Maternity case management as described in
			 the Medical-Surgical Services program rules (OAR chapter 410, division
			 130);
(w) Medical equipment and
			 supplies as described in the Hospital Services program, Medical-Surgical
			 Services program, DMEPOS program, Home Health Services program, Home
			 Enteral/Parenteral Nutrition and IV Services program, and other
			 rules;
(x) When a client's benefit
			 package includes mental health, the mental health services provided shall be
			 based on the Health Evidence Review Commission (HERC) Prioritized List of
			 Health Services;
(y) Naturopathic
			 services as described in the Medical-Surgical Services program rules (OAR
			 chapter 410, division 130);
(z)
			 Nutritional counseling as described in the Medical-Surgical Services program
			 rules (OAR chapter 410, division 130);
(aa) Occupational therapy as described in the
			 Physical and Occupational Therapy Services program rules (OAR chapter 410,
			 division 131);
(bb) Organ
			 transplant services as described in the Transplant Services program rules (OAR
			 chapter 410, division 124);
(cc)
			 Outpatient hospital services including clinic services, emergency department
			 services, physical and occupational therapy services, and any other outpatient
			 hospital services provided by and in a hospital as described in the Hospital
			 Services program rules (OAR chapter 410, division 125);
(dd) Physician, podiatrist, nurse
			 practitioner and licensed physician assistant services as described in the
			 Medical-Surgical Services program rules (OAR chapter 410, division
			 130);
(ee) Physical therapy as
			 described in the Physical and Occupational Therapy and the Hospital Services
			 program rules (OAR chapter 410, division 131 and 125);
(ff) Post-hospital extended care benefit as
			 described in OAR chapter 410, division 120 and 141 and Aging and People with
			 Disabilities (APD) program rules;
(gg) Prescription drugs including home
			 enteral and parenteral nutritional services and home intravenous services as
			 described in the Pharmaceutical Services program (OAR chapter 410, division
			 121), the Home Enteral/Parenteral Nutrition and IV Services program (OAR
			 chapter 410, division 148), and the Hospital Services program rules (OAR
			 chapter 410, division 125);
(hh)
			 Preventive services as described in the Medical-Surgical Services program (OAR
			 chapter 410, division 130), the Dental Services program rules (OAR chapter 410,
			 division 123), and prevention guidelines associated with the Health Evidence
			 Review Commission's Prioritized List of Health Services (OAR
			 410-141-0520);
(ii) Private duty
			 nursing as described in the Private Duty Nursing Services program rules (OAR
			 chapter 410, division 132);
(jj)
			 Radiology and imaging services as described in the Medical-Surgical Services
			 program rules (OAR chapter 410, division 130), the Hospital Services program
			 rules (OAR chapter 410, division 125), and Dental Services program rules (OAR
			 chapter 410, division 123);
(kk)
			 Rural health clinic services as described in the Federally Qualified Health
			 Center and Rural Health Clinic Program rules (OAR chapter 410, division
			 147);
(ll) School-based health
			 services as described in the School-Based Health Services Program rules (OAR
			 chapter 410, division 133);
(mm)
			 Speech and language therapy as described in the Speech-Language Pathology,
			 Audiology and Hearing Aid Services program rules (OAR chapter 410, division
			 129) and Hospital Services program rules (OAR chapter 410, division
			 125);
(nn) Transportation necessary
			 to access a covered medical service or item as described in the Medical
			 Transportation program rules (OAR chapter 410, division 136);
(oo) Vision services as described in the
			 Visual Services program rules (OAR chapter 410, division
			 140).