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Oregon Bulletin

January 1, 2014

Oregon Health Authority, Division of Medical Assistance Programs, Chapter 410

Rule Caption: Prescription Drug Monitoring Program

Adm. Order No.: DMAP 64-2013

Filed with Sec. of State: 11-19-2013

Certified to be Effective: 11-19-13

Notice Publication Date: 10-1-2013

Rules Amended: 410-121-4005, 410-121-4010, 410-121-4020

Subject: The Oregon Health Authority, Division of Medical Assistance Programs is permanently amending administrative rules in chapter 410, division 121 to add and revise definition terms; to revise reporting requirements; and to clarify expanded access to information in the electronic system.

Rules Coordinator: Sandy Cafourek—(503) 945-6530

410-121-4005

Definitions

Unless otherwise stated in OAR 410-121-4000 through 410-121-4020, or the context of OAR 410-121-4000 through 410-121-0420 requires otherwise, the following definitions apply to OAR 410-121-4000 through 410-121-0420:

(1) “Authority” means the Oregon Health Authority.

(2) “Controlled substance” means a prescription drug classified in Schedules II through IV under the Federal Controlled Substances Act, 21 U.S.C. 811 and 812, as modified under ORS 475.035.

(3) “Delegate” means a member of staff of a practitioner or pharmacist who is authorized by the practitioner or pharmacist to access the system on his or her behalf.

(4) “Dispense” and “dispensing” have the meaning given those terms in ORS 689.005.

(5) “Health professional regulatory board” has the meaning given that term in ORS 676.160.

(6) “Pharmacy” has the meaning given that term in ORS 689.005 but does not include a pharmacy in an institution as defined in ORS 179.010.

(7) “Practitioner” has the meaning given that term in ORS 431.960.

(8) “Prescription drug” has the meaning given that term in ORS 689.005.

(9) “System” means the secure electronic system used to monitor reported prescription drug information.

(10) “Unsecure data” means data that is electronic and is not encrypted at the level established by the National Institute of Standards and Technology.

(11) “Vendor” means the private entity under contract with the Authority to operate the system.

Stat. Auth.: ORS 431.962

Stats. Implemented: ORS 431.962 - 431.978 & 431.992

Hist,: DMAP 6-2011, f. & cert. ef. 5-5-11; DMAP 64-2013, f. & cert. ef. 11-19-13

410-121-4010

Reporting Requirements

(1) No later than one week after dispensing a controlled substance a pharmacy shall electronically report to the Authority the following information for prescription drugs dispensed that are classified in schedules II through IV under the federal Controlled Substances Act, 21 U.S.C. 811 and 812, as modified by the State Board of Pharmacy by rule under ORS 475.035:

(a) Patient’s full name, address, date of birth, and sex;

(b) Pharmacy Drug Enforcement Administration Registration Number (or other identifying number in lieu of such registration number);

(c) Prescriber name and Drug Enforcement Administration Registration Number (or other identifying number in lieu of such registration number);

(d) Identification of the controlled substance using a national drug code number;

(e) Prescription number;

(f) Date the prescription was written;

(g) Date the drug was dispensed;

(h) Number of metric units dispensed;

(i) Number of days supplied; and

(j) Number of refills authorized by the prescriber and the number of the fill of the prescription.

(2) A pharmacy located outside of the state and licensed by the Oregon Board of Pharmacy shall electronically report the required information for controlled substances dispensed to residents of Oregon.

(3) A pharmacy shall submit data formatted in the American Society for Automation in Pharmacy (ASAP) 2007 version 4 release 1 specification standard.

(4) Data submitted by a pharmacy shall meet criteria prescribed by the Authority before it is uploaded into the system.

(5) A pharmacy shall be responsible for the correction of errors in the submitted data. Corrections shall be submitted no later than one week after the data was submitted.

(6) A pharmacy that has not dispensed any controlled substances during a seven-day reporting period must submit a zero report to the Authority at the end of the reporting period.

(7) A pharmacy that does not dispense any controlled substances or any controlled substances directly to a patient may request a waiver from the Authority for exemption from the reporting requirement. A pharmacy requesting a no reporting waiver shall submit to the Authority a written waiver request form provided by the Authority.

(8) If the Authority approves or denies the no reporting waiver request, the Authority shall provide written notification of approval or denial to the pharmacy. The duration of the waiver shall be two years at which time the pharmacy must reapply.

(9) A pharmacy may request a waiver from the Authority for exemption from the electronic reporting method. A pharmacy requesting an electronic reporting waiver shall submit to the Authority a written waiver request form provided by the Authority that contains the reason for the requested waiver.

(10) The Authority may grant a waiver of the electronic reporting requirement for good cause as determined by the Authority. Good cause includes financial hardship and not having an automated recordkeeping system.

(a) If the Authority approves the electronic reporting waiver, the Authority shall provide written notification to the pharmacy. The Authority shall determine an alternative reporting method for the pharmacy granted a waiver. The duration of the waiver shall be two years at which time the pharmacy must reapply.

(b) If the Authority denies the electronic reporting waiver, the Authority shall provide written notification to the pharmacy explaining why the request was denied. The Authority may offer alternative suggestions for reporting to facilitate participation in the program.

Stat. Auth.: ORS 431.962

Stats. Implemented: ORS 431.962 & 431.964

Hist,: DMAP 6-2011, f. & cert. ef. 5-5-11; DMAP 64-2013, f. & cert. ef. 11-19-13

410-121-4020

Information Access

(1) System Access. Only the following individuals or entities may access the system:

(a) Practitioners and pharmacists authorized to prescribe or dispense controlled substances;

(b) Delegates;

(c) Designated representatives of the Authority and any vendor contracted to establish or maintain the system; and

(d) State Medical Examiner and designees of the State Medical Examiner.

(2) All entities or individuals who request access from the Authority for the creation of user accounts shall agree to terms and conditions of use of the system.

(3) All delegates must be authorized by a practitioner or pharmacist with an active system account.

(4) The Authority shall monitor the system for unusual and potentially unauthorized use. When such use is detected, the user account shall be immediately deactivated.

(5) The vendor, a practitioner, a pharmacist or a pharmacy shall report to the Authority within 24 hours any suspected breach of the system or unauthorized access.

(6) When the Authority is informed of any suspected breach of the system or unauthorized access, the Authority shall notify the Authority’s Information Security Office and investigate.

(7) If patient data is determined to have been breached or accessed without proper authorization, the Authority shall notify all affected patients, the Attorney General, and the applicable health professional regulatory board as soon as possible but no later than 30 days from the date of the final determination that a breach or unauthorized access occurred. Notice shall be made by first class mail to a patient or a patient’s next of kin if the patient is deceased. The notice shall include:

(a) The date the breach or unauthorized access was discovered and the date the Authority believes the breach or unauthorized access occurred;

(b) The data that was breached or accessed without proper authorization;

(c) Steps the individual can take to protect him or herself from identity or medical identity theft;

(d) Mitigation steps taken by the Authority; and

(e) Steps the Authority will take to reasonably ensure such a breach does not occur in the future.

(8) Practitioner, Pharmacist, and Delegate Access. A practitioner, pharmacist, or delegate who chooses to request access to the system shall apply for a user account as follows:

(a) Complete and submit an application provided by the Authority that includes identifying information and credentials;

(b) Agree to terms and conditions of use of the system that defines the limits of access, allowable use of patient information, and penalties for misuse of the system; and

(c) Mail to the Authority a notarized application.

(9) State Medical Examiner Access. The State Medical Examiner or his or her designee shall apply for a user account as required in section (8) of this rule and indicate their license type as Medical Examiner.

(10) The Authority shall compare the licensure requirements between Oregon practitioners and similarly licensed professionals in California, Idaho, and Washington. The Authority’s determination of similar licensure requirements shall be based upon scope of practice and formulary.

(11) The Authority shall review each application to authenticate before granting approval of a new account.

(12) If the Authority learns that an applicant has provided inaccurate or false information on an application, the Authority shall deny access to the system or terminate access to the system if access has already been established. The Authority may send written notification to the appropriate health professional regulatory board or oversight entity.

(13) A practitioner or pharmacist who is an authorized system user shall notify the Authority when his or her license or DEA registration has been limited, revoked, or voluntarily retired. A practitioner or pharmacist who changes or terminates employment shall notify the Authority of that change.

(14) When the Authority learns that a practitioner or pharmacist’s license has been limited or revoked, the Authority shall deny further access to the system.

(15) When a delegate for any reason is no longer authorized as a delegate by a practitioner or pharmacist, the practitioner or pharmacist shall revoke the delegation and notify the Authority.

(16) When the account of a delegate is inactive for more than six months, the account shall be deactivated by the Authority.

(17) When for any reason access of a designee of the State Medical Examiner must be revoked, the State Medical Examiner shall notify the Authority.

(18) Each time a practitioner or pharmacist makes a patient query he or she shall certify that requests are in connection with the treatment of a patient in his or her care and agree to terms and conditions of use of the system.

(19) Each time the State Medical Examiner or designee of the State Medical Examiner makes a patient query he or she shall certify that requests are for the purpose of conducting a specific medicolegal investigation or autopsy where there is reason to believe controlled substances contributed to the death and agree to terms and conditions of use of the system.

(20) Each time a delegate makes a patient query he or she shall certify that requests are in connection with the treatment of a patient of the practitioner or pharmacist for whom the delegate is conducting the query, agree to terms and conditions of use, and indicate the authorizing practitioner or pharmacist for whom the delegate is conducting the query.

(21) Practitioners and pharmacists with delegates must conduct monthly audits of delegate use to monitor for potential misuse of the system.

(22) When a practitioner or pharmacist learns of any potential unauthorized use of the system or system data by a delegate, the practitioner or pharmacist shall:

(a) Revoke the delegation; and

(b) Notify the Authority of the potential unauthorized use.

(23) When the State Medical Examiner learns of any potential unauthorized use of the system or system data by a designee, the State Medical Examiner shall notify the Authority.

(24) When the Authority learns of any potential unauthorized use of the system or system data, the Authority shall revoke the user’s access to the system, notify the Authority’s Information Security Office, and investigate.

(a) If the Authority determines unauthorized use occurred, the Authority shall send written notification to the appropriate health professional regulatory board, the Attorney General and all affected individuals.

(b) If the Authority determines unauthorized use did not occur, the Authority shall reinstate access to the system.

(25) The Authority shall send written notification to a user or a potential user when an account has been deactivated or access has been denied.

(26) Patient Access. A patient may request a report of the patient’s own controlled substance record. The patient shall mail to the Authority a request that contains the following documents:

(a) A signed and dated patient request form provided by the Authority; and

(b) A copy of the patient’s current valid U.S. driver’s license or other valid government issued photo identification.

(27) The Authority shall review the personal information submitted and verify that the patient’s identification and request match before taking further action.

(28) If the Authority cannot verify the information, the Authority shall send written notification to the patient explaining why the request cannot be processed.

(29) After the Authority has verified the request, the Authority shall query the system based upon the patient information provided in the request and securely send the report to the patient at no cost to the patient. The report shall include:

(a) A list of controlled substances dispensed to the patient including the dates of dispensation, the practitioners who prescribed the controlled substances, and the pharmacies that dispensed them; and

(b) A list of users who accessed the system for information on that specific patient with the date of each instance of access.

(30) If no data is found that matches the patient identified in the request, the Authority shall send written notification to the patient explaining possible reasons why no patient data was identified.

(31) A patient may send written notification to the Authority if he or she believes unauthorized access to his or her information has occurred. The notification shall include the patient’s name, who is suspected to have gained unauthorized access to the patient’s information, what information is suspected to have been accessed by unauthorized use, when the suspected unauthorized access occurred, and why the patient suspects the access was unauthorized. The Authority shall treat such patient notifications as potential unauthorized use of the system.

(32) A patient may request that the Authority correct information in a patient record report as follows:

(a) The patient shall specify in writing to the Authority what information in the report the patient considers incorrect.

(b) When the Authority receives a request to correct a patient’s information in the system, the Authority shall make a note in the system that the information is contested and verify the accuracy of the system data with the vendor. The vendor shall verify that the data obtained from the query is the same data received from the pharmacy.

(c) If the data is verified incorrect, the Authority shall correct the errors in consultation with the vendor and document the correction. The Authority shall send to the patient the corrected report.

(d) If the vendor verifies the data is correct, the Authority shall send written notification informing the patient that the request for correction is denied. The notice shall inform the patient of his or her rights as are applicable to the prescription drug monitoring program, the process for filing an appeal, and if there are no appeal rights, how to otherwise address or resolve the issue.

(33) The Authority shall respond to all patient requests within 10 business days after the Authority receives a request. Each response shall include information that informs the patient of his or her rights as are applicable to the prescription drug monitoring program.

(34) If the Authority denies a patient’s request to correct information, or fails to grant a patient’s request within 10 business days after the Authority receives the request, a patient may appeal the denial or failure by requesting a contested case hearing. The appeal shall be filed within 30 days after the request to correct information is denied. The appeal process is conducted pursuant to ORS chapter 183 and the Attorney General’s Uniform and Model Rules of Procedure for the Office of Administrative Hearings (OAH), OAR 137-003-0501 through 137-003-0700.

(35) Law Enforcement Access. A federal, state, or local law enforcement agency engaged in an authorized drug-related investigation of an individual may request from the Authority controlled substance information pertaining to the individual to whom the information pertains. The request shall be pursuant to a valid court order based on probable cause.

(36) A law enforcement agency shall submit to the Authority a request that contains the following:

(a) A form provided by the Authority specifying the information requested; and

(b) A copy of the court order documents.

(37) The Authority shall review the law enforcement request.

(a) If the form is complete and the court order is valid, the Authority shall query the system for the requested information and securely provide a report to the law enforcement agency.

(b) If the request or court order is not valid, the Authority shall respond to the law enforcement agency providing an explanation for the denial.

(38) Health Professional Regulatory Board Access. A health professional regulatory board investigating an individual regulated by the board may request from the Authority controlled substance information pertaining to the member.

(a) A health professional regulatory board shall submit to the Authority a form provided by the Authority specifying the information requested. The board’s executive director shall certify that the requested information is necessary for an investigation related to licensure, renewal, or disciplinary action involving the applicant, licensee, or registrant to whom the requested information pertains.

(b) The Authority shall review the regulatory board request.

(A) If a request is valid, the Authority shall query the system for the requested information and securely provide a report to the health professional regulatory board.

(B) If a request is not valid, the Authority shall respond to the health professional regulatory board providing an explanation for the denial.

(39) Researcher Access. The Authority may provide de-identified data for research purposes to a researcher. A researcher shall submit a research data request form provided by the Authority.

(a) The request shall include but is not limited to a thorough description of the study aims, data use, data storage, data destruction, and publishing guidelines.

(b) The Authority shall approve or deny research data requests based on application merit.

(c) If a request is approved, the requestor shall sign a data use agreement provided by the Authority.

(d) The Authority shall provide the minimum data set necessary that does not identify individuals.

(e) The Authority may charge researchers a reasonable fee for services involved in data access.

Stat. Auth.: ORS 431.962

Stats. Implemented: ORS 431.962 & 431.966

Hist,: DMAP 6-2011, f. & cert. ef. 5-5-11; DMAP 64-2013, f. & cert. ef. 11-19-13


Rule Caption: Add Dental Care Organization (DCO) language for dental integration into CCO’s

Adm. Order No.: DMAP 65-2013

Filed with Sec. of State: 11-29-2013

Certified to be Effective: 11-29-13

Notice Publication Date: 8-1-2013

Rules Amended: 410-141-3060, 410-141-3080, 410-141-3220, 410-141-3420

Subject: The Division needs to amend these rules to incorporate language related to dental services being integrated into the Coordinated Care Organizations (CCO). Changes have been made for clarity of rule language; the addition of effective dates, behavioral health and Dental Care Organization.

Rules Coordinator: Sandy Cafourek—(503) 945-6530

410-141-3060

Enrollment Requirements in a CCO

(1) A client who is eligible for or receiving health services must enroll in a CCO as required by ORS 414.631, except as provided in ORS 414.631(2), (3), (4), and (5) and 414.632(2) or exempted by this rule.

(2) If, upon application or redetermination, a client does not select a CCO, the Authority shall enroll the client and the client’s household in a CCO that has adequate health care access and capacity.

(3) For existing members of a PHP that has transitioned to a CCO, the Authority shall enroll those members in the CCO when the Authority certifies and contracts with the CCO. The Authority shall provide notice to the enrollees 30 days before the effective date.

(4) Existing members of a PHP that is on the path to becoming a CCO shall retain those members. The Authority shall enroll those members in the CCO when certification and contracting are complete. The Authority shall provide notice to the clients 30 days before the effective date.

(5) Unless otherwise exempted by sections (17) and (18) of this rule, existing clients receiving their physical health care services on a fee-for-service basis shall enroll in a CCO serving their area that has adequate health care access and capacity. They must enroll by November 1, 2012. The Authority shall send a notice to the clients 30 days before the effective date.

(6) The following apply to clients receiving physical health care services on a fee-for-service basis but managed or coordinated behavioral health services:

(a) The Authority shall enroll the client in a CCO that is serving the client’s area before November 1, 2012;

(b) The client shall receive their behavioral health care services from that CCO;

(c) The client shall continue to receive their physical health care services on a fee-for-service basis; and

(d) On or after November 1, 2012, the Authority shall enroll the client in a CCO for both physical health and behavioral health care services, unless otherwise exempted by sections (17) and (18) of this rule.

(e) On or after November 1, 2012, for the client exempt from coordinated physical health services by sections (17) and (18) shall receive managed or coordinated behavioral health services from a CCO or MHO.

(7) The following apply to clients enrolled in Medicare:

(a) A client may enroll in a CCO regardless of whether they are enrolled in Medicare Advantage;

(b) A client enrolled in Medicare Advantage, whether or not they pay their own premium, may enroll in a CCO, even if the CCO does not have a corresponding Medicare Advantage plan.

(c) A client may enroll with a CCO, even if the client withdrew from that CCO’s Medicare Advantage plan. The CCO shall accept the client’s enrollment if the CCO has adequate health access and capacity;

(d) A client may enroll with a CCO, even if the client is enrolled in Medicare Advantage with another entity.

(8) From August 1, 2012, until November 1, 2012, enrollment is required in service areas with adequate health care access and capacity to provide health care services through a CCO or PHP. The following outlines the priority of enrollment during this period in service areas where enrollment is required:

(a) Priority 1: The client must enroll in a CCO that serves that area and has adequate health care access and capacity;

(b) Priority 2: The client must enroll in a PHP if:

(A) A PHP serves an area that a CCO does not serve; or

(B) A PHP serves an area that a CCO serves, but the CCO has inadequate health care access and capacity to accept new members;

(c) Priority 3: The client shall receive services on a fee-for-service basis.

(9) From August 1, 2012, until November 1, 2012, enrollment is voluntary in service areas without adequate access and capacity to provide health care services through a CCO or PHP. If a client decides to enroll in a CCO or PHP, the priority of enrollment in section (8) applies.

(10) On or after November 1, 2012, CCO enrollment is required in all areas. The following outlines the priority of options to enroll in all service areas:

(a) Priority 1: The client must enroll in a CCO that serves that area and has adequate health care access and capacity;

(b) Priority 2: The client must enroll in a PHP on the path to becoming a CCO if:

(A) The PHP serves an area that a CCO does not serve; or

(B) The PHP serves an area that a CCO serves, but the CCO has inadequate health care services capacity to accept new members;

(c) Priority 3: The client must enroll in a PHP that is not on the path to becoming a CCO if:

(A) The PHP serves an area that a CCO does not serve; or

(B) The PHP serves an area that a CCO serves, but the CCO has inadequate health care access or capacity to accept new members;

(d) Priority 4: The client shall receive physical services on a fee-for-service basis.

(11) On or after July 1, 2013, a client must enroll in a CCO or managed dental care organization (DCO) in a service area where a CCO or DCO has adequate dental care access and capacity, and a CCO or DCO is open to enrollment. (13) If a client receives physical health care through a PHP, PCM or on a fee-for-service basis, under circumstances allowed by this rule, the client must enroll in a CCO or mental (behavioral) health organization (MHO) in a service area where MHO enrollment is required. The following determines if a service area requires CCO or MHO enrollment:

(a) CCO: The service area has adequate CCO behavioral health care access and capacity;

(b) MHO: A CCO does not serve in the area; or

(c) MHO: A CCO serves the area, but the CCO has inadequate health care access and capacity to accept new members:

(12) From August 1, 2012, until November 1, 2012, if a service area changes from required enrollment to voluntary enrollment, the member shall remain with the PHP for the remainder of their eligibility period or until the Authority or Department redetermines eligibility, whichever comes sooner, unless otherwise eligible to disenroll pursuant to OAR 410-41-3080.

(13) At the time of application or recertification, the primary person in the household shall select the CCO on behalf of all household members on the same household case. If the client is not able to choose a CCO, the client’s representative shall make the selection.

(14) The Department or OYA shall select the CCO for a child in the legal custody of the Department or OYA, except for children in subsidized adoptions.

(15) The following populations are exempt from CCO enrollment:

(a) Populations expressly exempted by ORS 414.631(2) (a), (b) and (c), which includes:

(A) Persons who are non-citizens who are eligible for labor and delivery services and emergency treatment services;

(B) Persons who are American Indian and Alaskan Native beneficiaries; and

(C) Persons who are dually eligible for Medicare and Medicaid and enrolled in a program of all-inclusive care for the elderly.

(b) Newly eligible clients are exempt from enrollment with a CCO if the client became eligible when admitted as an inpatient in a hospital. The client shall receive health care services on a fee-for-service basis only until the hospital discharges the client. The client is not exempt from enrollment in a DCO. The client is not exempt from enrollment in a DCO.

(c) Children in the legal custody of the Department or OYA where the child is expected to be in a substitute care placement for less than 30 calendar days, unless:

(A) Access to health care on a fee-for-service basis is not available; or

(B) Enrollment would preserve continuity of care.

(d) Clients with major medical health insurance coverage, also known as third party liability, except as provided in OAR 410-141-3050;

(e) Clients receiving prenatal services through the Citizen/Alien Waivered-Emergency Medical program; and

(f) Clients receiving premium assistance through the Specified Low-Income Medicare Beneficiary, Qualified Individuals, Qualified Disabled Working Individuals and Qualified Medicare Beneficiary programs.

(16) The following populations are exempt from CCO enrollment until specified below:

(a) From August 1, 2012, until November 1, 2012, children under 19 years of age who are medically fragile and who have special health care needs. Beginning November 1, 2012, the Authority may enroll these children in CCOs on a case-by-case basis; children not enrolled in a CCO shall continue to receive services on a FFS basis.

(b) Until July 1, 2014, women who are in their third trimester of pregnancy when first determined eligible for OHP or at re-determination may qualify as identified below to receive OHP benefits on a Fee-for-Service (FFS) basis until 60 days after the birth of her child. After the 60 day period the OHP member must enroll in a CCO. In order to qualify for the FFS third trimester exemption the member must:

(A) Not have been enrolled with a service area CCO, FCHP or PCO during the three months preceding re-determination,

(B) Have an established relationship with a licensed qualified practitioner who is not a participating provider with the service area CCO, FCHP or PCO and wishes to continue obtaining maternity services from the non-participating provider on a FFS basis, and

(C) Make a request to change to FFS prior to the date of the delivery if enrolled with a CCO, FCHP or PCO.

(c) From August 1, 2012 until November 1, 2012, clients receiving health care services through the Breast and Cervical Cancer Program are exempt. Beginning November 1, 2012, enrollment is required;

(d) Existing clients who had organ transplants are exempt until the Authority enrolls them in a CCO on a case-by-case basis; and

(e) From August 1, 2012, until November 1, 2012, clients with end-stage renal disease. Beginning November 1, 2012, enrollment is required.

(17) The following clients who are exempt from CCO enrollment and who receive services on a fee-for-service basis may enroll in a CCO:

(a) Clients who are eligible for both Medicare and Medicaid;

(b) Clients who are American Indian and Alaskan Native beneficiaries;

(18) The Authority may exempt clients or temporarily exempt clients for other just causes as determined by the Authority through medical review. The Authority may set an exemption period on a case-by-case basis. Other just causes include the considerations:

(a) Enrollment would pose a serious health risk; and

(b) The Authority finds no reasonable alternatives.

(19) The following pertains to the effective date of the enrollment. If the enrollment occurs:

(a) On or before Wednesday, the date of enrollment shall be the following Monday; or

(b) After Wednesday, the date of enrollment shall be one week from the following Monday.

(20) Coordinated care services shall begin on the first day of enrollment with the CCO except for:

(a) A newborn’s date of birth when the mother was a member of a CCO at the time of birth;

(b) For members who are re-enrolled within 30 calendar days of disenrollment, the date of enrollment shall be the date specified by the Authority that may be retroactive to the date of disenrollment;

(c) For adopted children or children placed in an adoptive placement, the date of enrollment shall be the date specified by the Authority.

Stat. Auth.: ORS 413.042, 414.615, 414.625, 414.635 & 414.651

Stats. Implemented: ORS 414.610 - 414.685

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 62-2012(Temp), f. 12-27-12, cert. ef. 1-1-13 thru 6-29-13; DMAP 4-2013(Temp), f. & cert. ef. 2-7-13 thru 6-29-13; DMAP 33-2013, f. & cert. ef. 6-27-13; DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 65-2013, f. & cert. ef. 11-29-13

410-141-3080

Disenrollment from Coordinated Care Organizations

(1) At the time of recertification, a member may disenroll from one CCO or DCO in a service area and enroll in another CCO or DCO in that service area. The primary person in the household shall make this decision on behalf of all household members.

(2) A member who moves from one service area to another service area shall disenroll from the CCO or DCO in the previous service area and enroll with a CCO or DCO in the new service area. The member must change their address with the Authority or Department within ten days of moving.

(3) A member who is an exempt client receiving services from a non-integrated CCO and wishes to receive services from an integrated CCO in their service area.

(4) A member who voluntarily enrolls in a CCO or DCO per OAR 410-141-3060(19) may disenroll from their CCOs or DCO’s at any time and receive health care services on a fee-for service basis or enroll in another CCO or DCO in their service area. This only applies to:

(a) Members who are eligible for both Medicare and Medicaid; and

(b) Members who are American Indian and Alaskan Native beneficiaries;

(c) Notwithstanding other sections of this rule, members may request disenrollment for just cause at any time pursuant to state law or CFR 438.56. This includes:

(A) The CCO or DCO does not cover the service the member seeks, because of moral or religious objections;

(B) The member needs related services (for example a cesarean section and a tubal ligation) to be performed at the same time, not all related services are available within the network, and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk; or

(C) The member is experiencing poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the member’s health care needs.

(5) The Authority may approve the disenrollment after medical review using the following just-cause considerations:

(a) Required enrollment would pose a serious health risk; and

(b) The Authority finds no reasonable alternatives.

(6) The following applies to time lines for clients to change their CCO or DCO assignment:

(a) Newly eligible clients may change their CCO or DCO assignment within 90 days of their application for health services;

(b) Existing members may change their CCO or DCO assignment within 30 days of the Authority’s automatic assignment in a CCO or DCO; or

(c) Members may change their CCO or DCO assignment upon eligibility redetermination.

(d) Members may change enrollment in their CCO or DCO once during each enrollment period.

(7) Pursuant to CFR 438.56, the CCO or DCO shall not request and the Authority shall not approve disenrollment of a member due to:

(a) A physical or behavioral disability or condition;

(b) An adverse change in the member’s health;

(c) The member’s utilization of services, either excessive or lacking;

(d) The member’s decisions regarding medical care with which the CCO or DCO disagrees;

(e) The member’s behavior is uncooperative or disruptive, including but not limited to threats or acts of physical violence, resulting from the member’s special needs, except when continued enrollment in the CCO or DCO seriously impairs the CCO’s or DCO’s ability to furnish services to this particular member or other members.

(8) A CCO or DCO may request the Authority to disenroll a member if the CCO or DCO determines:

(a) Except as provided in OAR 410-141-3050, the member has major medical coverage, including employer sponsored insurance (ESI);

(b) The CCO or DCO determines:

(A) The member has moved to a service area the CCO or DCO does not serve;

(B) The member is out of the CCO’s or DCO’s area for three months without making arrangements with the CCO or DCO;

(C) The member did not initiate enrollment in the CCO or DCO serving the member’s area; and

(D) The member is not in temporary placement or receiving out-of-area services.

(c) The member is in a state psychiatric institution;

(d) The CCO or DCO has verifiable information that the member has moved to another Medicaid jurisdiction; or

(e) The member is deceased.

(9) Before requesting disenrollment under the exception in section (7)(e) of this rule, a CCO or DCO must take meaningful steps to address the member’s behavior, including but not limited to:

(a) Contacting the member either orally or in writing to explain and attempt to resolve the issue. The CCO or DCO must document all oral conversations in writing and send a written summary to the member. This contact may include communication from advocates, including peer wellness specialists, where appropriate, personal health navigators and qualified community health workers who are part of the member’s care team to provide assistance that is culturally and linguistically appropriate to the member’s need to access appropriate services and participate in processes affecting the member’s care and services;

(b) Developing and implementing a care plan in coordination with the member and the member’s care team that details the problem and how the CCO or DCO shall address it;

(c) Reasonably modifying practices and procedures as appropriate to accommodate the member’s circumstances;

(d) Assessing the member’s behavior to determine if it results from the member’s special needs or a disability;

(e) Providing education, counseling and other interventions to resolve the issue; and

(f) Submitting a complete summary to the Authority if the CCO or DCO requests disenrollment.

(10) The Authority may disenroll members of CCOs or DCOs for the reasons specified in Section (8) without receiving a disenrollment request from a CCO or DCO.

(11) The CCO or DCO shall request the Authority to suspend a member’s enrollment when the inmate is incarcerated in a State or Federal prison, a jail, detention facility or other penal institution for no longer than 12 months. The CCO or DCO shall request that the Authority disenroll a member when the inmate is incarcerated in a State or Federal prison, jail, detention facility or other institution for longer than 12 months. This does not include members on probation, house arrest, living voluntarily in a facility after adjudication of their case, infants living with inmates or inmates admitted for inpatient hospitalization. The CCO or DCO is responsible for identifying the members and providing sufficient proof of incarceration to the Authority for review of the request for suspension of enrollment or disenrollment. CCOs shall pay for inpatient services only during the time a member is an inmate and enrollment is otherwise suspended.

(12) Unless otherwise specified in these rules or in the Authority notification of disenrollment to the CCO or DCO, all disenrollments are effective at the end of the month the Authority approves the disenrollment, with the following exceptions;

(a) The Authority may specify a retroactive disenrollment effective date if the member has:

(A) Third party coverage including employee-sponsored insurance. The effective date shall be the date the coverage begins;

(B) Enrolls in a program for all-inclusive care for the elderly (PACE). The effective date shall be the day before PACE enrollment;

(C) Is admitted to the State Hospital. The effective date shall be the day before hospital admission; or

(D) Becomes deceased. The effective date shall be the date of death.

(b) The Authority may retroactively disenroll or suspend enrollment if the member is incarcerated pursuant to section (11) of this rule. The effective date shall be the date of the notice of incarceration or the day before incarceration, whichever is earlier.

(c) The Authority shall specify a disenrollment effective date if the member moves out of the CCO’s or DCO’s service area. The Authority shall recoup the balance of that month’s capitation payment from the CCO or DCO;

(d) The Authority may specify the disenrollment effective date if the member is no longer eligible for OHP;

(13) The Authority shall inform the members of a disenrollment decision in writing, including the right to request a contested case hearing to dispute the Authority’s disenrollment if the Authority disenrolled the member for cause that the member did not request. If the member requests a hearing, the disenrollment shall remain in effect pending outcome of the contested case hearing.

(14) For purposes of a member’s right to a contested case hearing, “disenrollment” does not include the Authority’s:

(a) Transfer of a member from a PHP to a CCO or DCO;

(b) Transfer of a member from a CCO or DCO to another CCO or DCO; or

(c) Automatic enrollment of a member in a CCO or DCO.

(15) The Authority may approve the transfer of 500 or more members from one CCO or DCO to another CCO or DCO if:

(a) The members’ provider has contracted with the receiving CCO or DCO and has stopped accepting patients from or has terminated providing services to members in the transferring CCO or DCO; and

(b) Members are offered the choice of remaining enrolled in the transferring CCO or DCO.

(16) Members may not be transferred under section (15) until the Authority has evaluated the receiving CCO or DCO and determined that the CCO or DCO meets criteria established by the Authority by rule, including but not limited to ensuring that the CCO or DCO maintains a network of providers sufficient in numbers and areas of practice and geographically distributed in a manner to ensure that the health services provided under the contract are reasonably accessible to members.

(17) The Authority shall provide notice of a transfer under section (15) to members that will be affected by the transfer at least 90 days before the scheduled date of the transfer.

(18) Except as otherwise allowed by rule, a member may transfer from one CCO or DCO to another CCO or DCO no more than once during each enrollment period.

Stat. Auth.: ORS 413.032, 414.615, 414.625, 414.635 & 414.651

Stats. Implemented: ORS 414.610 - 414.685

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 47-2012(Temp), f. & cert. ef. 10-16-12 thru 4-13-13; DMAP 55-2012(Temp), f. & cert. ef. 11-15-12 thru 4-13-13; Administrative correction 4-22-13; DMAP 19-2013, f. & cert. ef. 4-23-13; DMAP 25-2013, f. & cert. ef. 6-11-13; DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 65-2013, f. & cert. ef. 11-29-13

410-141-3220

Accessibility

(1) Consistent with the community health assessment and health improvement plan, CCOs must assure that members have access to high quality care. The CCO shall accomplish this developing a provider network that demonstrates communication, collaboration, and shared decision making with the various providers and care settings. The CCO shall develop and implement the assessment and plan over time that meets access-to-care standards, and allows for appropriate choice for members. The goal shall be that services and supports should be geographically as close as possible to where members reside and, to the extent necessary, offered in nontraditional settings that are accessible to families, diverse communities, and underserved populations.

(2) CCOs shall ensure access to integrated and coordinated care as outlined in OAR 410-141-3160, which includes access to a primary care provider or primary care team that is responsible for coordination of care and transitions.

(3) In developing its access standards, the CCO should anticipate access needs, so that the members receive the right care at the right time and place, using a patient-centered approach. The CCO provider network shall support members, especially those with behavioral health issues, in the most appropriate and independent setting, including in their own home or independent supported living.

(4) CCOs shall have policies and procedures which ensure that for 90% of their members in each service area, routine travel time or distance to the location of the PCPCH or PCP does not exceed the community standard for accessing health care participating providers. The travel time or distance to PCPCHs or PCPs shall not exceed the following, unless otherwise approved by the Authority:

(a) In urban areas-30 miles, 30 minutes or the community standard, whichever is greater;

(b) In rural areas-60 miles, 60 minutes or the community standard, whichever is greater.

(5) CCOs shall have an access plan that establishes standards for access, outlines how capacity is determined and establishes procedures for monthly monitoring of capacity and access, and for improving access and managing risk in times of reduced participating provider capacity. The access plan shall also identify populations in need of interpreter services and populations in need of accommodation under the Americans with Disabilities Act.

(6) CCOs shall make the services it provides including: primary care, specialists, pharmacy, hospital, vision, ancillary, and behavioral health services, as accessible to members for timeliness, amount, duration, and scope as those services are to other members within the same service area. If the CCO is unable to provide those services locally, it must so demonstrate to the Authority and provide reasonable alternatives for members to access care that must be approved by the Authority. CCOs shall have a monitoring system that shall demonstrate to the Authority that the CCO has surveyed and monitored for equal access of members to referral providers of pharmacy, hospital, vision, ancillary, and behavioral health services:

(a) CCOs shall ensure that PCPs screen all eligible members for behavioral health issues to promote prevention, early detection, intervention and referral to treatment, especially at initial contact or physical exam or at initial prenatal examination, when a member shows evidence of behavioral health issues or when a member over utilizes services;

(b) CCOs must use a universal screening process that assesses members for critical risk factors that trigger intensive care coordination for high-needs members.

(7) CCOs shall have policies and procedures and a monitoring system to ensure that members who are aged, blind, or disabled, or who have complex or high health care needs, multiple chronic conditions, behavioral health issues or who are children receiving Department or OYA services have access to primary care, dental care (when the CCO or DCO is responsible for dental care), mental health providers and referral, and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services.

(8) CCOs shall have policies and procedures that ensure scheduling and rescheduling of member appointments are appropriate to the reasons for, and urgency of, the visit. The member shall be seen, treated, or referred as within the following timeframes:

(a) Emergency care-Immediately or referred to an emergency department depending on the member’s condition;

(b) Urgent care-Within 72 hours or as indicated in initial screening, in accordance with OAR 410-141-0140;

(c) Well care-Within 4 weeks or within the community standard;

(d) Emergency dental care (when dental care is provided by the CCO or DCO)-Seen or treated within 24- hours;

(e) Urgent dental care (when dental care is provided by the CCO or DCO)-Within one to two weeks or as indicated in the initial screening in accordance with OAR 410-123-1060; and

(f) Routine dental care (when dental care is provided by the CCO or DCO)-Seen for routine care within an average of eight weeks and within 12 weeks or the community standard, whichever is less, unless there is a documented special clinical reason which would make access longer than 12 weeks appropriate;

(g) Non-Urgent behavioral health treatment-Seen for an intake assessment within 2 weeks from date of request.

(9) CCOs shall develop policies and procedures for communicating with, and providing care to members who have difficulty communicating due to a medical condition or who are living in a household where there is no adult available to communicate in English or here there is no telephone:

(a) The policies and procedures shall provide certified or qualified interpreter services by phone, in person, in CCO administrative offices, especially those of member services and complaint and grievance representatives and in emergency rooms of contracted hospitals;

(b) CCOs shall ensure the provision of certified or qualified interpreter services for covered coordinated care services including medical, behavioral health or dental care (when the CCO or DCO is responsible for dental care) visits, and home health visits, to interpret for members with hearing impairment or in the primary language of non-English speaking members. All interpreters shall be linguistically appropriate and be capable of communicating in English and the members’ primary language and be able to translate clinical information effectively. Interpreter services shall be sufficient for the provider to understand the member’s complaint; to make a diagnosis; respond to member’s questions and concerns; and to communicate instructions to the member;

(c) CCOs shall ensure the provision of coordinated care services which are culturally appropriate, i.e., demonstrating both awareness for and sensitivity to cultural differences and similarities and the effect on the members’ care;

(d) CCOs shall have written policies and procedures that ensure compliance with requirements of the Americans with Disabilities Act of 1990 in providing access to covered coordinated care services for all members and shall arrange for services to be provided by non- participating referral providers when necessary;

(e) CCOs shall have a plan for ensuring compliance with these requirements and shall monitor for compliance.

Stat. Auth.: ORS 413.032, 414.615, 414.625, 414.635 & 414.651

Stats. Implemented: ORS 414.610 - 414.685

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 65-2013, f. & cert. ef. 11-29-13

410-141-3420

Billing and Payment

(1) Subject to other applicable Division billing rules, providers must submit all billings for CCO members following the timeframes in (a) and (b) below:

(a) Submit billings within twelve (12) months of the date of service in the following cases:

(A) Member pregnancy;

(B) Eligibility issues such as retroactive deletions or retroactive enrollments;

(C) Medicare is the primary payer, except where the CCO is responsible for the Medicare reimbursement;

(D) Other cases that could have delayed the initial billing to the CCO (which does not include failure of provider to certify the member’s eligibility); or

(E) Third Party Liability (TPL). Pursuant to 42 CFR 136.61, subpart G: Indian Health Services and the amended Public Law 93-638 under the Memorandum of Agreement that Indian Health Service and 638 Tribal Facilities are the payer of last resort and is not considered an alternative liability or TPL.

(b) Submit bills within four (4) months of the date of service for all other cases.

(2) Providers must be enrolled with the Authority’s Division of Medical Assistance Programs to be eligible for fee-for-service (FFS) payments. Mental health providers, except Federally Qualified Health Centers (FQHC), must be approved by the Local Mental Health Authority (LMHA) and the Authority’s Addictions and Mental Health (AMH) Division before enrollment with the Authority or to be eligible for CCO payment for services. Providers may be retroactively enrolled, in accordance with OAR 410-120-1260 (Provider Enrollment).

(3) Providers, including mental health providers, must be enrolled with the Authority as a Medicaid provider or an encounter-only provider prior to submission of encounter data to ensure the encounter is accepted.

(4) Providers shall verify, before providing services, that the member is eligible for coordinated care services on the date of service. Providers shall use the Authority tools and the CCO’s tools, as applicable, to determine if the service to be provided is covered under the member’s Oregon Health Plan Benefit Package of covered services. Providers shall also identify the party responsible for covering the intended service and seek pre-authorizations from the appropriate payer before providing services. Before providing a non-covered service, the provider must complete a DMAP 3165, or facsimile, signed by the client, as described in OAR 141-120-1280.

(5) CCOs shall pay for all covered coordinated care services. These services must be billed directly to the CCO, unless the CCO or the Authority specifies otherwise. CCOs may require providers to obtain preauthorization to deliver certain coordinated care services.

(6) Payment by the CCO to participating providers for coordinated care services is a matter between the CCO and the participating provider, except as follows:

(a) CCOs shall have procedures for processing pre-authorization requests received from any provider. The procedures shall specify time frames for:

(A) Date stamping pre-authorization requests when received;

(B) Determining within a specific number of days from receipt whether a pre-authorization request is valid or non-valid;

(C) The specific number of days allowed for follow up on pended preauthorization requests to obtain additional information;

(D)The specific number of days following receipt of the additional information that a redetermination must be made;

(E) Providing services after office hours and on weekends that require preauthorization;

(F) Sending notice of the decision with appeal rights to the member when the determination is a denial of the requested service as specified in OAR 410-141-3263.

(b) CCOs shall make a determination on at least 95 percent of valid preauthorization requests, within two working days of receipt of a preauthorization or reauthorization request related to urgent services; alcohol and drug services; or care required while in a skilled nursing facility. Preauthorization for prescription drugs must be completed and the pharmacy notified within 24 hours. If a preauthorization for a prescription cannot be completed within the 24 hours, the CCO must provide for the dispensing of at least a 72-hour supply if there is an immediate medical need for the drug. CCOs shall notify providers of the determination within 2 working days of receipt of the request;

(c) For expedited prior authorization requests in which the provider indicates, or the CCO determines, that following the standard timeframe could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function:

(A) The CCO must make an expedited authorization decision and provide notice as expeditiously as the member’s health or mental health condition requires and no later than three working days after receipt of the request for service;

(B) The CCO may extend the three working day time period no more than 14 calendar days if the member requests an extension, or if the CCO justifies to the Authority a need for additional information and how the extension is in the member’s best interest.

(d) For all other preauthorization requests, CCOs shall notify providers of an approval, a denial or the need for further information within 14 calendar days of receipt of the request, as outlined in 410-141-3263, CCOs must make reasonable efforts to obtain the necessary information during the 14-day period. However, the CCO may use an additional 14 days to obtain follow-up information, if the CCO justifies (to the Authority upon request) the need for additional information and how the delay is in the interest of the member. The CCO shall make a determination as the member’s health or mental health condition requires, but no later than the expiration of the extension.

(7) CCOs shall have written procedures for processing payment claims submitted from any source. The procedures shall specify time frames for:

(a) Date stamping claims when received;

(b) Determining within a specific number of days from receipt whether a claim is valid or non-valid;

(c) The specific number of days allowed for follow up of pended claims to obtain additional information;

(d) The specific number of days following receipt of additional information that a determination must be made; and

(e) Sending notice of the decision with appeal rights to the member when the determination is made to deny the claim;

(f) CCOs shall pay or deny at least 90 percent of valid claims within 45 calendar days of receipt and at least 99 percent of valid claims within 60 calendars days of receipt. CCOs shall make an initial determination on 99 percent of all claims submitted within 60 calendar days of receipt;

(g) CCOs shall provide written notification of CCO determinations when the determinations result in a denial of payment for services as outlined in 410-141-3263;

(h) CCOs may not require providers to delay billing to the CCO;

(i) CCOs may not require Medicare be billed as the primary insurer for services or items not covered by Medicare, or require non-Medicare approved providers to bill Medicare;

(j) CCOs may not deny payment of valid claims when the potential TPR is based only on a diagnosis, and no potential TPR has been documented in the member’s clinical record;

(k) CCOs may not delay or deny payments because a co-payment was not collected at the time of service.

(8) CCOs shall pay for Medicare coinsurances and deductibles up to the Medicare or CCOs allowable for covered services the member receives within the CCO, for authorized referral care, and urgent care services or emergency services the member receives from non-participating providers. CCOs may not pay for Medicare coinsurances and deductibles for non-urgent or non-emergent care members receive from non-participating providers.

(9) CCOs shall pay transportation, meals and lodging costs for the member and any required attendant for services that the CCO has arranged and authorized when those services are not available within the state, unless otherwise approved by the Authority.

(10) CCOs shall pay for covered services provided by a non-participating provider which was not pre-authorized if the following conditions exist:

(a) It can be verified that the participating provider ordered or directed the covered services to be delivered by a non-participating provider; and

(b) The covered service was delivered in good faith without the pre-authorization; and

(c) It was a covered service that would have been pre-authorized with a participating provider if the CCO’s referral procedures had been followed;

(d) The CCO shall pay non-participating providers (providers enrolled with the Authority that do not have a contract with the CCO) for covered services that are subject to reimbursement from the CCO, in the amount specified in OAR 410-120-1295. This rule does not apply to providers that are Type A or Type B hospitals;

(e) CCOs shall reimburse hospitals for services provided on or after January 1, 2012 using Medicare Severity DRG for inpatient services and Ambulatory Payment Classification (APC) for outpatient services or other alternative payment methods which incorporate the most recent Medicare payment methodologies for both inpatient and outpatient services established by CMS for hospital services; and alternative payment methodologies, including but not limited to pay-for-performance, bundled payments and capitation. An alternative payment methodology does not include reimbursement payment based on percentage of billed charges. This requirement does not apply to Type A or Type B hospitals as referenced in ORS 442.470. CCO shall attest annually to the Authority, in a manner to be prescribed, to CCO’s compliance with these requirements.

(11) Members may receive certain services on a Fee for Service (FFS) basis:

(a) Certain services must be authorized by the CCO or the Community Mental Health Program (CMHP) for some mental health services, even though the services are then paid by the Authority on a FFS basis. Before providing services, providers must verify a member’s eligibility using the web portal or AVR;

(b) Services authorized by the CCO or CMHP are subject to the rules and limitations of the appropriate Authority administrative rules and supplemental information, including rates and billing instructions;

(c) Providers shall bill the Authority directly for FFS services in accordance with billing instructions contained in the Authority administrative rules and supplemental information;

(d) The Authority shall pay at the Medicaid FFS rate in effect on the date the service is provided subject to the rules and limitations described in the relevant rules, contracts, billing instructions;

(e) The Authority may not pay a provider for provision of services for which a CCO has received a CCO payment unless otherwise provided for in rule;

(f) When an item or service is included in the rate paid to a medical institution, a residential facility or foster home, provision of that item or service is not the responsibility of the Authority or a CCO except as provided in Authority administrative rules and supplemental information (e.g., coordinated care services that are not included in the nursing facility all-inclusive rate);

(g) CCOs that contract with FQHCs and RHCs shall negotiate a rate of reimbursement that is not less than the level and amount of payment which the CCO would pay for the same service furnished by a provider, who is not an FQHC nor RHC, consistent with the requirements of BBA 4712(b)(2).

(12) Coverage of services through the Oregon Health Plan Benefit Package of covered services is limited by OAR 410-141-0500, excluded services and limitations for OHP clients.

Stat. Auth.: ORS 414.032, 414.615, 414.625, 414.635, 414.651

Stats. Implemented: ORS 414.610 – 685 OL 2011, Ch 602 Sec. 13, 14, 16, 17, 62, 64 (2), 65, HB 3650

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 60-2013, f. & cert. ef. 10-31-13; DMAP 65-2013, f. & cert. ef. 11-29-13


Rule Caption: Process for Traditional Health Worker Training, Certification, Registry Enrollment and Training Program Criteria

Adm. Order No.: DMAP 66-2013

Filed with Sec. of State: 12-3-2013

Certified to be Effective: 12-3-13

Notice Publication Date: 7-1-2013

Rules Adopted: 410-180-0300, 410-180-0305, 410-180-0310, 410-180-0312, 410-180-0315, 410-180-0320, 410-180-0327, 410-180-0340, 410-180-0345, 410-180-0350, 410-180-0355, 410-180-0360, 410-180-0370, 410-180-0375, 410-180-0380

Rules Repealed: 410-180-0300(T), 410-180-0305(T), 410-180-0310(T), 410-180-0315(T), 410-180-0320(T), 410-180-0327(T), 410-180-0340(T), 410-180-0345(T), 410-180-0350(T), 410-180-0355(T), 410-180-0370(T), 410-180-0375(T), 410-180-0380(T)

Subject: House Bill 3650, passed during the 2011 legislative session, mandates that members enrolled in Oregon’s Coordinated Care Organizations (CCOs) have access to Traditional Health Workers (THWs) to facilitate culturally and linguistically appropriate care. THWs include community health workers, personal health navigators, peer wellness specialists, and other health care workers who are not regulated or certified by this state. These rules establish:

   The competency requirements for each THW type, including Community Health Workers, Peer Wellness Specialists, Personal Health Navigators, Peer Support Specialists, and Birth Doulas;

   Eligibility requirements, curriculum guidelines and procedures for Authority approval of training programs, including a process for temporary waivers;

   Eligibility requirements and procedures for THW certification and provisional certification; and

   A THW registry maintained by the Authority.

   These rules set forth the requirements for training programs in developing curricula that meet the Authority’s requirements to certify THWs. Individuals who successfully complete the certification process set forth in these rules will be eligible for Medicaid reimbursement for their services. These rules also establish a registry of THWs whom CCOs may employ to meet the requirement of providing for their members, THW’s including peer wellness specialists, personal health navigators, community health workers, peer support specialists, and birth doulas as part of the member’s care team to provide assistance that is culturally and linguistically appropriate. These rules also set forth provisional THW certification requirements.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-180-0300

Purpose

The purpose of these rules is to establish criteria, description, and training requirements for Traditional Health Workers (THW) which include community health workers, personal health navigators, peer wellness specialists and other health care workers not regulated or certified by the state of Oregon. These rules set forth the procedures for THW certification and enrollment in a registry maintained by the Authority. These rules also establish curriculum guidelines for training programs seeking to train THWs and the procedures for Authority approval of training programs.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0305

Definitions

The following definitions apply to OAR 410-180-0300 through 410-180-0380:

(1) “Authority” means the Oregon Health Authority.

(2) “Authority Approved Training Program” (Training program) means an organization that has a training program with curriculum that meets Authority standards for one or more types of THWs and has been approved by the Authority to train those types of THWs.

(3) “Birth Doula” means a birth companion who provides personal, nonmedical support to women and families throughout a woman’s pregnancy, childbirth, and post-partum experience.

(4) “Certified Traditional Health Worker” means an individual who has successfully completed a training program as required by these rules, and has applied for and been certified by the Authority for one of the THW types; or a grandfathered THW who has been certified by the Authority.

(5) “Community Based Organization” (CBO) means a public or private nonprofit organization that is representative of a community or significant segments of a community, which may be located within or in close proximity to the community it serves; and is engaged in meeting that community’s needs in the areas of social, human, or health services.

(6) “Community Health Worker” has the meaning given that term in ORS 414.025.

(7) “Contact Hour” means a training hour, which includes classroom, group or distance learning. Contact hour does not include homework time, preparatory reading, or practicum.

(8) “Competencies” mean key skills and applied knowledge necessary for THWs to be effective in the work field and carry out their roles.

(9) “Equivalency” means an individual has fulfilled the requirements of a course or combination of courses, by completing a relatively equivalent course.

(10) “Grandfathered THW” means an individual who has been certified by the Authority as an THW as a result of their prior THW work experience and fulfillment of all additional requirements for grandfathering as set forth in these rules.

(11) “Incumbent Worker Training” means training offered by an approved training program for individuals eligible for grandfathering that assesses for and addresses any gaps in THW competencies.

(12) “Peer” means any individual who has similar life experience, either as a current or former recipient of addictions or mental health services, or as a family member of an individual who is a current or former recipient of addictions or mental health services.

(13) “Peer Support Specialist” means a person providing peer delivered services to an individual or family member with similar life experience. A peer support specialist must be:

(a) A self-identified person currently or formerly receiving mental health services; or

(b) A self-identified person in recovery from an addiction disorder, who meets the abstinence requirements for recovering staff in alcohol and other drug treatment programs;

(c) A self-identified person in recovery from problem gambling; or

(d) A family member of an individual who is a current or former recipient of addictions or mental health services.

(14) “Peer Wellness Specialist” has the meaning given that term in ORS 414.025.

(15) “Personal Health Navigator” has the meaning given that term in ORS 414.025.

(16) “Provisionally Certified THW” means an individual who has temporary certified status, pursuant to OAR 410-180-0327.

(17) “Registry” means a list of certified THWs maintained by the Authority.

(18) “THW Applicant” means an individual who has applied for THW certification.

(19) “Traditional Health Worker” (THW) means a community health worker, peer wellness specialist, personal health navigator, peer support specialist or birth doula.

(20) “Training Program Applicant” means an organization that has applied for Authority approval of its training program and curricula for any of the THW types.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0310

Community Health Worker, Peer Wellness Specialist, Personal Health Navigator Certification Requirements

(1) To be certified as a community health worker, peer wellness specialist, or personal health navigator, an individual must successfully complete all required training offered by a training program for that individual’s THW type.

(2) Individuals who have worked or volunteered in the capacity of a community health worker, peer wellness specialist or personal health navigator in the state of Oregon at least 3000 hours from January 1, 2004 to June 30, 2014 but have not completed a training program are eligible for certification if they successfully complete approved incumbent worker training.

(3) Individuals who have completed some or all of the certification training requirements may receive equivalency for previously completed training. The training program shall determine equivalency requirements.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0312

Peer Support Specialist Certification Requirements

(1) To be certified as a peer support specialist, an individual must:

(a) Successfully complete all required training offered by a training program for peer support specialist; or

(b) Be certified by an entity whose qualifications for the certificate includes completion of an Authority approved training program for peer support specialists and a minimum of 20 hours of continuing education every three years.

(2) Individuals who have worked or volunteered in the capacity of a peer support specialist in the state of Oregon at least 2000 hours from January 1, 2004 to June 30, 2014 but have not completed a training program are eligible for certification if they successfully complete an approved incumbent worker training.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0315

Birth Doula Certification Requirements

To be certified in Oregon as a birth doula, an individual must:

(1) Successfully complete an approved birth doula training program; or

(2) Have successfully completed all birth doula training requirements as described in OAR 410-180-0375 through one or a combination of non-approved birth doula training programs and meet the cultural competency course requirements through an approved training program for doulas.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0320

THW Continuing Education Requirements

(1) To maintain certification status, all THWs must complete at least 20 hours of continuing education during every three year renewal period.

(2) Continuing education hours taken in excess of the total number required may not be carried over to the next renewal period.

(3) The Authority shall award continuing education hours for:

(a) Additional THW training offered by a training program; and

(b) Any other Authority approved training or event.

(4) Requests for approval of continuing education may come from the hosting organization or from a certified THW attending the training or event.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0327

Provisional THW Certification

(1) Individuals may qualify for provisional certification if:

(a) They are eligible for grandfathering as described in OAR 410-180-0310 and 410-180-0312 but have not yet completed incumbent worker training; or

(b) They have completed or matriculated in a non-approved training program between February 4, 2010 and August 2, 2013 provided:

(A) The individual successfully completes the training program; and

(B) The training program includes a minimum of 40 contact hours of training.

(2) Individuals seeking provisional certification must:

(a) Be at least 18 years of age;

(b) Submit a completed application on an Authority prescribed form; and

(c) Submit one of the following:

(A) Verifiable evidence of working or volunteering in the capacity of a community health worker, peer wellness specialist, or personal health navigator for at least 3000 hours from January 1, 2004 to June 30, 2014; or

(B) Verifiable evidence of working or volunteering in the capacity of a peer support specialist for at least 2000 hours from January 1, 2004 to June 30, 2014; or

(C) Written documentation of successful completion of a training program that includes at minimum 40 contact hours of training.

(3) Applications are available on the THW program webpage or a paper copy may be obtained upon request to the Oregon Health Authority Office of Equity and Inclusion.

(4) If the Authority determines that an applicant has met all provisional certification requirements, the Authority shall notify the applicant in writing granting provisional certification.

(5) Provisionally certified THWs may become certified if:

(a) The individual successfully completes remaining training requirements or incumbent worker training from a training program within one year from the provisional certification date; or

(b) The non-approved training program completed by the provisionally certified THW becomes Authority approved.

(6) Provisionally certified THWs seeking certification must comply with OAR 410-180-0325.

(7) The Authority shall revoke provisional certification if the individual does not complete the remaining training requirements within one year from the date of provisional certification.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0340

Standards of Professional Conduct

(1) A certified or provisionally certified THW, pursuant to OAR 410-180-0305 must comply with Standards of Professional Conduct set forth in this rule. The violation of the standards may result in the denial of an application for certification or suspension or revocation of certification.

(2) THWs must:

(a) Acquire, maintain and improve professional knowledge and competence using scientific, clinical, technical, psychosocial, governmental, cultural and community-based sources of information;

(b) Represent all aspects of professional capabilities and services honestly and accurately;

(c) Ensure that all actions with community members are based on understanding and implementing the core values of caring, respect, compassion, appropriate boundaries, and appropriate use of personal power;

(d) Develop positive collaborative partnerships with community members, colleagues, other health care providers, and the community to provide care, services, and supports that are safe, effective, and appropriate to a community member’s needs;

(e) Regardless of clinical diagnosis, develop and incorporate respect for diverse community member backgrounds including lifestyle, sexual orientation, race, gender, ethnicity, religion, age, marital status, political beliefs, socioeconomic status or any other preference or personal characteristic, condition or state when planning and providing services;

(f) Act as an advocate for community members and their needs;

(g) Support self-determination and advocate for the needs of community members in a culturally competent, trauma informed manner

(h) Base decisions and actions in support of empowerment and respect for community member’s culture and self-defined health care goals using sound ethical reasoning and current principles of practice;

(i) Maintain individual confidentiality; and

(j) Recognize and protect an individual’s rights as described in section (3) of this rule.

(3) Individuals being served have the right to:

(a) Be treated with dignity and respect;

(b) Be free from theft, damage, or misuse of personal property;

(c) Be free from neglect of care, verbal, mental, emotional, physical, and sexual abuse;

(d) Be free from financial exploitation;

(e) Be free from physical restraints;

(f) Voice grievances or complaints regarding services or any other issue without discrimination or reprisal for exercising their rights;

(g) Be free from discrimination in regard to race, color, national origin, gender, sexual orientation, or religion; and

(h) Have their information and records confidentially maintained.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0345

Denial, Suspension or Revocation of Certification

(1) The Authority may deny, suspend, or revoke certification when an applicant or certificate holder fails to comply with ORS 414.665 or these rules.

(2) The Authority shall deny, suspend, or revoke certification pursuant to ORS 183.411 through 183.470 and the applicant or certificate holder may request a contested case hearing.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0350

Training Program Requirements

(1) All training programs must:

(a) Meet the curriculum requirements for the THW type being trained;

(b) Demonstrate active efforts to establish equivalency for students who have previously completed training that meets one or more training requirements for their THW type;

(c) Demonstrate active efforts to involve experienced THWs in developing and teaching the core curriculum;

(d) Demonstrate active efforts to collaborate with at least one culturally diverse CBO;

(e) Demonstrate the use of various teaching methodologies including but not limited to popular education and adult learning;

(f) Demonstrate the use of various training delivery formats including but not limited to classroom instruction, group and distance learning;

(g) Demonstrate efforts to make training inclusive and accessible to individuals with different learning styles, education backgrounds, and student needs;

(h) Demonstrate efforts to remove barriers to enrollment for students;

(i) Demonstrate inclusion of cognitive and practical examinations to evaluate and document the acquisition of knowledge and mastery of skills by the individual trained. This examination:

(A) May be any combination of written, oral, or practical competency tests; and

(B) Must assess THW competencies covered in the curriculum.

(j) Demonstrate the inclusion of a method or process for the individual trained to evaluate and give feedback on the training experience;

(k) Maintain an accurate record of each individual’s attendance and participation in training for at least five years after course completion;

(l) Agree to verify and provide the Authority with names of individuals who successfully completed the training program when those individuals apply for certification and registry enrollment; and

(m) Agree to issue a written letter of completion to all successful training program graduates.

(2) All training programs that provide incumbent worker training for individuals eligible to grandfather into the NTHW program must also:

(a) Require students to submit an Authority prescribed competency evaluation form from any previous employer, THW coach or supervisor or volunteer coordinator or supervisor for whom THW services have been provided in the five years prior to the date of application

(b) Include a pre-course assessment to evaluate student’s current level of knowledge and skill; and

(c) Provide training that addresses gaps in competencies identified in the employer competency evaluation and pre-course assessment.

(3) Training program applicants must submit an application to the Authority. At a minimum, the training program application must include:

(a) Contact information for the individual or entity, including director name and contact information;

(b) Syllabus and course materials that demonstrate curriculum requirements are met; language per comment #23 above.

(c) Indication of the training type to be offered:

(A) Curriculum for community health workers, peer wellness specialists, peer support specialists, personal health navigators, and birth doulas; and

(B) Additional curriculum for:

(i) Community health workers;

(ii) Peer wellness specialists

(iii) Peer support specialists; and

(iv) Incumbent worker training

(d) An overview of the teaching philosophy and methodology;

(e) A description of the method of final examination as described in section (1) (h);

(f) A list of instructors, including experienced THWs if available;

(g) A description of the geographic area served;

(h) If the applicant is not a CBO, a signed agreement with description of the partnership with a CBO;

(i) A description of the approach for recruiting and enrolling a diverse student population to meet the needs of the community, including any strategies for reducing barriers to enrollment; and

(j) An indication of whether academic credit may be given for successful completion of training program.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0355

Application and Renewal Process for Authority Training Program Approval

(1) Training program applications are available on the THW program webpage or by requesting a paper copy from the Oregon Health Authority Office of Equity and Inclusion.

(2) Training program applicants must submit an application at least 90 days in advance of the first expected class day.

(3) If an application is incomplete, the Authority shall send notice requesting the additional materials required. The notice shall specify the date by which additional materials must be submitted. Unless the Authority grants an extension, if the applicant does not respond within the specified time, the Authority shall return the application to the applicant and take no further action.

(4) If the Authority determines that an applicant has met all training program requirements, the Authority shall send written notice of program approval. The written notice of Authority approval shall be made available to any student or partnering organization that requests a copy.

(5) The Authority shall maintain a list of training programs. The list shall be available to the public.

(6) The training program must apply to renew its approval status every three years.

(a) Renewal applications are available on the THW program webpage or by requesting a paper copy from the Oregon Health Authority Office of Equity and Inclusion.

(b) Training programs must complete and submit the renewal application no less than six months prior to the expiration of the current approval period.

(c) At a minimum, training programs seeking renewal shall report:

(A) Summary of any proposed changes to the curriculum;

(B) Number of students trained in the three year approval period

(7) Training programs that fail to submit a renewal application pursuant to section (6) (b) of this rule must submit a new application and may not apply for renewal of its current approval.

(8) The Authority may conduct site visits of training programs, either prior to approving or renewing a training program application, or at any time during the three year approval period.

(9) During the three year approval period, any change made to a training program shall be reported to the Authority within 30 days of the decision to make the change.

(a) Changes that must be reported include:

(A) Changes to the training program director or primary contact;

(B) Changes to the teaching methodology;

(C) Changes to the curriculum; and

(D) Any other change that is not consistent with or not represented in the initial application for approval.

(b) If the Authority determines that the reported changes meet the training program requirements described in OAR 410-180-0350, the Authority shall approve the change.

(c) The Authority may request additional information and justification for the reported change.

(d) If the Authority determines that the reported changes do not comply with the training program requirements described in OAR 410-180-0350, the Authority may deny the change or revoke training program approval.

(10) A training program applicant or approved training program may request a temporary waiver from a requirement in these rules. A request for a waiver must be:

(a) Submitted to the Authority in writing;

(b) Identify the specific rule for which a waiver is requested;

(c) Identify the special circumstances relied upon to justify the waiver;

(d) Describe alternatives that were considered, if any, and why alternatives, including compliance, were not selected;

(e) Demonstrate that the proposed waiver is desirable to maintain or improve the training of THWs; and

(f) Indicate the proposed duration of the waiver, not to exceed one year.

(11) If the Authority determines that the applicant or program has satisfied the conditions of this rule, the Authority may grant a waiver.

(12) An applicant or an approved training program may not act on or implement a waiver until it has received written approval from the Authority.

(13) AMH peer support specialist training programs approved prior to August 2, 2013 may remain approved if:

(a) The program currently provides a minimum of 40 hours of training; or

(b) The program increases its curriculum to a minimum of 40 hours of training.

(c) The program must submit to the Authority a peer support specialist program renewal application by October 2, 2013

(A) The renewal application and waiver request is available on THW program webpage or by requesting a paper copy from the Oregon Health Authority Office of Equity and Inclusion;

(B) If the renewal application is not submitted before October 2, 2013, the program must apply as a new training program.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0360

Denial, Suspension or Revocation of Training Program Approval

(1) The Authority may deny, suspend or revoke training program approval when an applicant or approved program has failed to comply with ORS 414.665 or these rules.

(2) If the Authority denies, suspends, or revokes approval it shall send written notice and explain the basis for its decision.

(3) An applicant or approved training program may request that the Authority reconsider its decision and may request a meeting with Authority staff. The request for reconsideration and a meeting, if requested, must be submitted in writing within 30 days of the date the Authority mailed the written decision of denial, suspension or revocation. The request must contain a detailed statement with supporting documentation explaining why the requestor believes the Authority’s decision is in error. The Authority shall issue a written decision on reconsideration following review of the materials submitted by the applicant or training program and a meeting with the applicant or training program, if applicable.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0370

Community Health Workers, Peer Wellness Specialists, Personal Health Navigators, and Peer Support Specialists Certification Curriculum Standards

(1) All Authority approved curricula used to train community health workers, peer wellness specialists and personal health navigators must:

(a) Include a minimum of 80 contact hours, which addresses the core curricula topics set forth in section (2) of this rule and any other additional curriculum topics specific to the type of worker being trained;

(b) Provide training that addresses all the major roles and core competencies of community health workers, peer wellness specialists and personal health navigators in Oregon as listed and defined in Oregon Health Policy Board’s Report “The Role of Non-Traditional Health Workers in Oregon’s Health Care System” incorporated by reference. (http://www.oregon.gov/oha/oei/docs/nthw-report-120106.pdf, January 2012)

(2) An Authority approved core curriculum for community health workers, peer wellness specialists and personal health navigators shall, at a minimum, introduce students to the key principles of the following topics:

(a) Community Engagement, Outreach Methods and Relationship Building;

(b) Communication Skills, including cross-cultural communication, active listening, and group and family dynamics;

(c) Empowerment Techniques;

(d) Knowledge of Community Resources;

(e) Cultural Competency and Cross Cultural Relationships, including bridging clinical and community cultures;

(f) Conflict Identification and Problem Solving;

(g) Conducting Individual Strengths and Needs Based Assessments;

(h) Advocacy Skills;

(i) Ethical Responsibilities in a Multicultural Context;

(j) Legal Responsibilities;

(k) Crisis Identification and Problem-Solving;

(l) Professional Conduct, including culturally appropriate relationship boundaries and maintaining confidentiality;

(m) Navigating Public and Private Health and Human Service Systems, including state, regional, and local;

(n) Working with Caregivers, Families, and Support Systems, including paid care workers;

(o) Trauma-Informed Care, including screening and assessment, recovery from trauma, minimizing re-traumatization;

(p) Self-Care;

(q) Social Determinants of Health;

(r) Building Partnerships with Local Agencies and Groups;

(s) The Role and Certified Scope of Practice of Traditional Health Workers;

(t) Roles, expectations, and supervisory relationships for Working in Multidisciplinary Teams, including supervisory relationships;

(u) Data Collection and Types of Data;

(v) Organization Skills and Documentation and use of HIT;

(w) Introduction to Disease Processes, including chronic diseases, mental health, tobacco cessation, and addictions (warning signs, basic symptoms, when to seek medical help);

(x) Health Across the Life Span;

(y) Adult Learning Principles - Teaching and Coaching;

(z) Stages of Change;

(aa) Health Promotion Best Practices; and

(bb) Health Literacy Issues.

(3) In addition to the core curriculum set forth in section (2), training programs for community health workers shall include the following topics:

(a) Self-Efficacy;

(b) Community Organizing;

(c) Group Facilitation Skills;

(d) Conducting Community Needs Assessments;

(e) Popular Education Methods; and

(f) Principles of Motivational interviewing.

(4) In addition to the core curriculum, set forth in section (2) training programs for peer wellness specialists shall include the following topics:

(a) Self-Efficacy;

(b) Group Facilitation Skills;

(c) Cultivating Individual Resilience;

(d) Recovery, Resilience and Wellness Models; and

(e) Principles of Motivational interviewing.

(5) An Authority approved curriculum for peer support specialists shall include a minimum of 40 contact hours that include:

(a) The core curriculum set forth in section (2)(a) through (p);

(b) The Role and Scope of Practice of Peer Support Specialists; and

(c) Recovery, Resilience and Wellness.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0375

Birth Doula Certification Curriculum Standards

(1) All Authority approved curricula used to train birth doulas must include a minimum of the following:

(a) 16 contact hours in Labor Support training;

(b) 4 contact hours in Breastfeeding training;

(c) 12 contact hours in Childbirth Education; and

(d) 6 contact hours in Cultural Competency training.

(2) Authority approved birth doula training curricula must also incorporate the following components and students must:

(a) Be CPR-certified for children and adults;

(b) Read five books from an Authority approved reading list;

(c) Write a 500 to 1000 word essay on the value of labor support;

(d) Create a community resource list;

(e) Submit evaluations from work with three families and one provider;

(f) Attend at least three births and three postpartum visits; and

(g) Have a valid food handler’s permit.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13

410-180-0380

THW and Training Program Complaints and Investigations

(1) Any individual may make a complaint verbally or in writing to the Authority regarding an allegation as to the care or services provided by a certified or provisionally certified THW pursuant to OAR 410-180-0305 or that an approved training program has violated THW statutes or these rules.

(2) The identity of an individual making a complaint shall be kept confidential to the extent permitted by law but may be disclosed as necessary to conduct the investigation and may include but is not limited to disclosing the complainant’s identity to the THW’s employer.

(3) If a complaint involves an allegation of criminal conduct or that is within the jurisdiction of another local, state, or federal agency, the Authority shall refer the matter to the appropriate agency.

(4) The Authority shall investigate complaints and take any actions that are necessary for resolution. An investigation may include but is not limited to:

(a) Interviews of the complainant, program management or staff, and other students; or

(b) Interviews of the complainant, caregivers, clients, client’s representative, client’s family members, and witnesses, and employer management and staff;

(c) On-site observations of the training program, the client, THW performance and client environment; and

(d) Review of documents and records.

(e) Utilize complaint and investigation findings to identify trends and potential areas for quality improvement.

Stat. Auth.: ORS 413.042, 414.635 & 414.665

Stats. Implemented: ORS 414.635 & 414.665

Hist.: DMAP 42-2013(Temp), f. & cert. ef. 8-2-13 thru 1-29-14; DMAP 66-2013, f. & cert. ef. 12-3-13


Rule Caption: Statewide CHIP funded CAWEM prenatal program

Adm. Order No.: DMAP 67-2013

Filed with Sec. of State: 12-3-2013

Certified to be Effective: 12-3-13

Notice Publication Date: 11-1-2013

Rules Amended: 410-120-0030

Subject: The General Rules program administrative rules govern Division payments for services to clients. The Division needs to amend 410-120-0030 to include coverage statewide. The Division will amend this rule to include coverage for prenatal care; retroactive to October 1, 2013.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-120-0030

Children’s Health Insurance Program

(1) The Children’s Health Insurance Program (CHIP) is a federal non-entitlement program. The Oregon Health Authority, Division of Medical Assistance Program (Division) administers two programs funded under CHIP in accordance with the Oregon Health Plan waiver and the CHIP state plan.

(a) CHIP: Provides health coverage for uninsured, low-income children who are ineligible for Medicaid;

(b) CHIP prenatal care expansion program.

(2) The General Rules Program (OAR 410-120-0000 et. seq.) and Oregon Health Plan Program rules (OAR 410-141-0000 et. seq.) applicable to the Medicaid program are also applicable to the Authority’s CHIP program.

(3) Children under 19 years of age, who meet the income limits, citizenship requirements and eligibility criteria for medical assistance established in OAR chapter 461 through the program acronym OHP-CHP, receive the OHP Plus benefit package (for benefits refer to OAR 410-120-1210).

(4) CHIP Prenatal care expansion coverage: Women not eligible for Medicaid at or below 185% of the FPL, with the benefit package identifier CWX:

(a) Receive the OHP Plus benefit package with limitations as described in subsection (d) of these rules;

(b) Effective October 1, 2013 resides in the state during pregnancy.

(c) The day after pregnancy ends, eligibility for medical services is based on eligibility categories established in OAR chapter 461;

(d) The following services are not covered for this program:

(A) Postpartum care (except when provided and billed as part of a global obstetric package code that includes the delivery procedure);

(B) Sterilization;

(C) Abortion;

(D) Death with dignity services;

(E) Hospice.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: DMAP 7-2008(Temp), f. 3-17-08 & cert. ef. 4-1-08 thru 9-15-08; DMAP 14-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 29-2009(Temp), f. 9-15-09, cert. ef. 10-1-09 thru 3-25-10; DMAP 37-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 18-2010, f. 6-23-10, cert. ef. 7-1-10; DMAP 23-2010, f. & cert. ef. 9-1-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 19-2012, f. 3-30-12, cert. ef. 4-1-12; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 67-2013, f. & cert. ef. 12-3-13


Rule Caption: Expand age for varnish in medical setting and update language for dental integration

Adm. Order No.: DMAP 68-2013

Filed with Sec. of State: 12-5-2013

Certified to be Effective: 12-23-13

Notice Publication Date: 11-1-2013

Rules Amended: 410-123-1260

Subject: Revises language based on Health Evidence Review Commission’s Prioritized List changes for October 1, 2013. Clarifies billing to avoid ambiguity regarding the responsibility of Coordinated Care Organizations (CCO).

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-123-1260

OHP Plus Dental Benefits

(1) GENERAL:

(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT):

(A) Refer to Code of Federal Regulations (42 CFR 441, Subpart B) and OAR chapter 410, division 120 for definitions of the EPSDT program, eligible clients, and related services. EPSDT dental services includes, but are not limited to:

(i) Dental screening services for eligible EPSDT individuals; and

(ii) Dental diagnosis and treatment which is indicated by screening, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health;

(B) Providers must provide EPSDT services for eligible Division clients according to the following documents:

(i) The Dental Services Program administrative rules (OAR chapter 410, division 123), for dentally appropriate services funded on the Oregon Health Evidence Review Commission Prioritized List of Health Services (Prioritized List); and

(ii) The “Oregon Health Plan (OHP), Recommended Dental Periodicity Schedule,” dated January 1, 2010, incorporated by reference and posted on the Division Web site in the Dental Services Provider Guide document at www.oha.state.or.us/policy/healthplan/guides/dental/main.html;

(b) Restorative, periodontal and prosthetic treatments:

(A) Treatments must be consistent with the prevailing standard of care, documentation must be included in the client’s charts to support the treatment, and may be limited as follows:

(i) When prognosis is unfavorable;

(ii) When treatment is impractical;

(iii) A lesser-cost procedure would achieve the same ultimate result; or

(iv) The treatment has specific limitations outlined in this rule;

(B) Prosthetic treatment, including porcelain fused to metal crowns, are limited until rampant progression of caries is arrested and a period of adequate oral hygiene and periodontal stability is demonstrated; periodontal health needs to be stable and supportive of a prosthetic.

(2) DIAGNOSTIC SERVICES:

(a) Exams:

(A) For children (under 19 years of age):

(i) The Division shall reimburse exams (billed as D0120, D0145, D0150, or D0180) a maximum of twice every 12 months with the following limitations:

(I) D0150: once every 12 months when performed by the same practitioner;

(II) D0150: twice every 12 months only when performed by different practitioners;

(III) D0180: once every 12 months;

(ii) The Division shall reimburse D0160 only once every 12 months when performed by the same practitioner;

(B) For adults (19 years of age and older), the Division shall reimburse exams (billed as D0120, D0150, D0160, or D0180) once every 12 months;

(C) For problem focused exams (urgent or emergent problems), the Division shall reimburse D0140 for the initial exam. The Division shall reimburse D0170 for related problem focused follow-up exams. Providers should not bill D0140 and D0170 for routine dental visits;

(D) The Division only covers oral exams by medical practitioners when the medical practitioner is an oral surgeon;

(E) As the American Dental Association’s Current Dental Terminology (CDT) codebook specifies the evaluation, diagnosis and treatment planning components of the exam are the responsibility of the dentist, the Division may not reimburse dental exams when furnished by a dental hygienist (with or without an expanded practice permit);

(b) Assessments of a patient (D0191):

(A) When performed by a dental practitioner, the Division shall reimburse:

(i) If performed by a dentist outside of a dental office;

(ii) If performed by a dental hygienist with an expanded practice dental hygiene permit;

(iii) Only if an exam (D0120-D0180) is not performed on the same date of service. An oral assessment is included in the exam;

(iii) For children (under 19 years of age), a maximum of twice every 12 months; and

(iv) For adults (age 19 and older), a maximum of once every 12 months;

(B) When performed by a medical practitioner, the Division shall cover:

(i) Only for children under 7 years of age; and

(ii) A maximum of once a year;

(C) Medical practitioners performing D0191 shall bill the client’s medical coverage for reimbursement (Coordinated Care Organization (CCO) or Prepaid Health Plan (PHP) if enrolled member, or Division if fee-for-service);

(D) The maximum limits for this procedure for dental practitioners do not affect the maximum limits for medical providers, and vice versa; and

(E) An assessment does not take the place of the need for oral evaluations/exams;

(c) Radiographs:

(A) The Division shall reimburse for routine radiographs once every 12 months;

(B) The Division shall reimburse bitewing radiographs for routine screening once every 12 months;

(C) The Division shall reimburse a maximum of six radiographs for any one emergency;

(D) For clients under age six, radiographs may be billed separately every 12 months as follows:

(i) D0220-once;

(ii) D0230-a maximum of five times;

(iii) D0270-a maximum of twice, or D0272 once;

(E) The Division shall reimburse for panoramic (D0330) or intra-oral complete series (D0210) once every five years, but both cannot be done within the five-year period;

(F) Clients must be a minimum of six years old for billing intra-oral complete series (D0210). The minimum standards for reimbursement of intra-oral complete series are:

(i) For clients age six through 11-a minimum of 10 periapicals and two bitewings for a total of 12 films;

(ii) For clients ages 12 and older-a minimum of 10 periapicals and four bitewings for a total of 14 films;

(G) If fees for multiple single radiographs exceed the allowable reimbursement for a full mouth complete series (D0210), the Division shall reimburse for the complete series;

(H) Additional films may be covered if dentally or medically appropriate, e.g., fractures (Refer to OAR 410-123-1060 and 410-120-0000);

(I) If the Division determines the number of radiographs to be excessive, payment for some or all radiographs of the same tooth or area may be denied;

(J) The exception to these limitations is if the client is new to the office or clinic and the office or clinic was unsuccessful in obtaining radiographs from the previous dental office or clinic. Supporting documentation outlining the provider’s attempts to receive previous records must be included in the client’s records;

(K) Digital radiographs, if printed, should be on photo paper to assure sufficient quality of images.

(3) PREVENTIVE SERVICES:

(a) Prophylaxis:

(A) For children (under 19 years of age), limited to twice per 12 months;

(B) For adults (19 years of age and older), limited to once per 12 months;

(C) Additional prophylaxis benefit provisions may be available for persons with high risk oral conditions due to disease process, pregnancy, medications or other medical treatments or conditions, severe periodontal disease, rampant caries and/or for persons with disabilities who cannot perform adequate daily oral health care;

(D) Are coded using the appropriate Current Dental Terminology (CDT) coding:

(i) D1110 (Prophylaxis-Adult), Use for clients 14 years of age and older; and

(ii) D1120 (Prophylaxis-Child), Use for clients under 14 years of age;

(b) Topical fluoride treatment:

(A) For adults (19 years of age and older), limited to once every 12 months;

(B) For children (under 19 years of age), limited to twice every 12 months;

(C) For children under 19 years of age, topical fluoride varnish may be applied by a medical practitioner during a medical visit:

(i) Bill the Division directly when the client is fee-for-service (FFS), is enrolled in a CCO that does not include integrated dental services, or is enrolled in a PHP that does not include integrated dental services;

(ii) Bill the client’s Coordinated Care Organization (CCO) if the client is enrolled in a CCO that includes integrated dental services;

(iii) Bill using a professional claim format with the appropriate CDT code (D1206-Topical Fluoride Varnish);

(D) Additional topical fluoride treatments may be available, up to a total of 4 treatments per client within a 12-month period, when high-risk conditions or oral health factors are clearly documented in chart notes for the following clients who:

(i) Have high-risk oral conditions due to disease process, medications, other medical treatments or conditions, or rampant caries;

(ii) Are pregnant;

(iii) Have physical disabilities and cannot perform adequate, daily oral health care;

(iv) Have a developmental disability or other severe cognitive impairment that cannot perform adequate, daily oral health care; or

(v) Are under seven years old with high-risk oral health factors, such as poor oral hygiene, deep pits and fissures (grooves) in teeth, severely crowded teeth, poor diet, etc.;

(E) Fluoride limits include any combination of fluoride varnish (D1206) or other topical fluoride (D1208);

(c) Sealants (D1351):

(A) Are covered only for children under 16 years of age;

(B) The Division limits coverage to:

(i) Permanent molars; and

(ii) Only one sealant treatment per molar every five years, except for visible evidence of clinical failure;

(d) Tobacco cessation:

(A) For services provided during a dental visit, bill as a dental service using CDT code D1320 when the following brief counseling is provided:

(i) Ask patients about their tobacco-use status at each visit and record information in the chart;

(ii) Advise patients on their oral health conditions related to tobacco use and give direct advice to quit using tobacco and a strong personalized message to seek help; and

(iii) Refer patients who are ready to quit, utilizing internal and external resources to complete the remaining three A’s (assess, assist, arrange) of the standard intervention protocol for tobacco;

(B) The Division allows a maximum of 10 services within a three-month period;

(C) For tobacco cessation services provided during a medical visit follow criteria outlined in OAR 410-130-0190;

(e) Space management:

(A) The Division shall cover fixed and removable space maintainers (D1510, D1515, D1520, and D1525) only for clients under 19 years of age;

(B) The Division may not reimburse for replacement of lost or damaged removable space maintainers.

(4) RESTORATIVE SERVICES:

(a) Restorations-amalgam and composite:

(A) The Division shall cover resin-based composite restorations only for anterior teeth (D2330-D2390) and one surface posterior tooth (D2391);

(B) Resin-based composite crowns on anterior teeth (D2390) are only covered for clients under 21 years of age or who are pregnant;

(C) The Division reimburses posterior composite restorations at the same rate as amalgam restorations;

(D) The Division limits payment for replacement of posterior composite restorations to once every five years;

(D) The Division limits payment of covered restorations to the maximum restoration fee of four surfaces per tooth. Refer to the American Dental Association (ADA) CDT codebook for definitions of restorative procedures;

(E) Providers must combine and bill multiple surface restorations as one line per tooth using the appropriate code. Providers may not bill multiple surface restorations performed on a single tooth on the same day on separate lines. For example, if tooth #30 has a buccal amalgam and a mesial-occlusal-distal (MOD) amalgam, then bill MOD, B, using code D2161 (four or more surfaces);

(F) The Division may not reimburse for an amalgam or composite restoration and a crown on the same tooth;

(G) The Division reimburses for a surface once in each treatment episode regardless of the number or combination of restorations;

(H) The restoration fee includes payment for occlusal adjustment and polishing of the restoration;

(b) Crowns and related services:

(A) General payment policies:

(i) The fee for the crown includes payment for preparation of the gingival tissue;

(ii) The Division shall cover crowns only when:

(I) There is significant loss of clinical crown and no other restoration will restore function; and

(II) The crown-to-root ratio is 50:50 or better and the tooth is restorable without other surgical procedures;

(iii) The Division shall cover core buildup (D2950) only when necessary to retain a cast restoration due to extensive loss of tooth structure from caries or a fracture and only when done in conjunction with a crown. Less than 50% of the tooth structure must be remaining for coverage of the core buildup. The Division may not cover core buildup if the crown is not covered under the client’s OHP benefit package;

(iv) Reimbursement of retention pins (D2951) is per tooth, not per pin;

(B) The Division shall not cover the following services:

(i) Endodontic therapy alone (with or without a post);

(ii) Aesthetics (cosmetics);

(iii) Crowns in cases of advanced periodontal disease or when a poor crown/root ratio exists for any reason;

(C) The Division shall cover acrylic heat or light cured crowns (D2970 temporary crown, fractured tooth), allowed only for anterior permanent teeth;

(D) The Division shall cover the following only for clients under 21 years of age or who are pregnant:

(i) Prefabricated plastic crowns (D2932), allowed only for anterior teeth, permanent or primary;

(ii) Stainless steel crowns (D2930/D2931), allowed only for anterior primary teeth and posterior permanent or primary teeth;

(iii) Prefabricated stainless steel crowns with resin window (D2933), allowed only for anterior teeth, permanent or primary;

(iv) Prefabricated post and core in addition to crowns (D2954/D2957);

(v) Permanent crowns (resin-based composite-D2710 and D2712, and porcelain fused to metal (PFM), D2751 and D2752) as follows:

(I) Limited to teeth numbers 6–11, 22 and 27 only, if dentally appropriate;

(II) Limited to four in a seven-year period. This limitation includes any replacement crowns allowed according to (E)(i) of this rule;

(III) Only for clients at least 16 years of age; and

(IV) Rampant caries are arrested and the client demonstrates a period of oral hygiene before prosthetics are proposed;

(vi) PFM crowns (D2751 and D2752) must also meet the following additional criteria:

(I) The dental practitioner has attempted all other dentally appropriate restoration options, and documented failure of those options;

(II) Written documentation in the client’s chart indicates that PFM is the only restoration option that will restore function;

(III) The dental practitioner submits radiographs to the Division for review; history, diagnosis, and treatment plan may be requested. See OAR 410123-1100 (Services Reviewed by the Division of Medical Assistance Programs);

(IV) The client has documented stable periodontal status with pocket depths within 1–3 millimeters. If PFM crowns are placed with pocket depths of 4 millimeter and over, documentation must be maintained in the client’s chart of the dentist’s findings supporting stability and why the increased pocket depths will not adversely affect expected long term prognosis;

(V) The crown has a favorable long-term prognosis; and

(VI) If tooth to be crowned is clasp/abutment tooth in partial denture, both prognosis for crown itself and tooth’s contribution to partial denture must have favorable expected long-term prognosis;

(E) Crown replacement:

(i) Permanent crown replacement limited to once every seven years;

(ii) All other crown replacement limited to once every five years; and

(iii) The Division may make exceptions to crown replacement limitations due to acute trauma, based on the following factors:

(I) Extent of crown damage;

(II) Extent of damage to other teeth or crowns;

(III) Extent of impaired mastication;

(IV) Tooth is restorable without other surgical procedures; and

(V) If loss of tooth would result in coverage of removable prosthetic;

(F) Crown repair (D2980) is limited to only anterior teeth.

(5) ENDODONTIC SERVICES:

(a) Pulp capping:

(A) The Division includes direct and indirect pulp caps in the restoration fee; no additional payment shall be made for clients with the OHP Plus benefit package;

(B) The Division covers direct pulp caps as a separate service for clients with the OHP Standard benefit package because restorations are not a covered benefit under this benefit package;

(b) Endodontic therapy:

(A) Pulpal therapy on primary teeth (D3230 and D3240) is covered only for clients under 21 years of age;

(B) For permanent teeth:

(i) Anterior and bicuspid endodontic therapy (D3310 and D3320) is covered for all OHP Plus clients; and

(ii) Molar endodontic therapy (D3330):

(I) For clients through age 20, is covered only for first and second molars; and

(II) For clients age 21 and older who are pregnant, is covered only for first molars;

(C) The Division covers endodontics only if the crown-to-root ratio is 50:50 or better and the tooth is restorable without other surgical procedures;

(c) Endodontic retreatment and apicoectomy/periradicular surgery:

(A) The Division does not cover retreatment of a previous root canal or apicoectomy/periradicular surgery for bicuspid or molars;

(B) The Division limits either a retreatment or an apicoectomy (but not both procedures for the same tooth) to symptomatic anterior teeth when:

(i) Crown-to-root ratio is 50:50 or better;

(ii) The tooth is restorable without other surgical procedures; or

(iii) If loss of tooth would result in the need for removable prosthodontics;

(C) Retrograde filling (D3430) is covered only when done in conjunction with a covered apicoectomy of an anterior tooth;

(d) The Division does not allow separate reimbursement for open-and-drain as a palliative procedure when the root canal is completed on the same date of service, or if the same practitioner or dental practitioner in the same group practice completed the procedure;

(e) The Division covers endodontics if the tooth is restorable within the OHP benefit coverage package;

(f) Apexification/recalcification and pulpal regeneration procedures:

(A) The Division limits payment for apexification to a maximum of five treatments on permanent teeth only;

(B) Apexification/recalcification and pulpal regeneration procedures are covered only for clients under 21 years of age or who are pregnant.

(6) PERIODONTIC SERVICES:

(a) Surgical periodontal services:

(A) Gingivectomy/Gingivoplasty (D4210 and D4211) — limited to coverage for severe gingival hyperplasia where enlargement of gum tissue occurs that prevents access to oral hygiene procedures, e.g., Dilantin hyperplasia; and

(B) Includes six months routine postoperative care;

(C) The Division shall consider gingivectomy or gingivoplasty to allow for access for restorative procedure, per tooth (D4212) as part of the restoration and will not provide a separate reimbursement for this procedure;

(b) Non-surgical periodontal services:

(A) Periodontal scaling and root planing (D4341 and D4342):

(i) For clients through age 20, allowed once every two years;

(ii) For clients age 21 and over, allowed once every three years;

(iii) A maximum of two quadrants on one date of service is payable, except in extraordinary circumstances;

(iv) Quadrants are not limited to physical area, but are further defined by the number of teeth with pockets 5 mm or greater:

(I) D4341 is allowed for quadrants with at least four or more teeth with pockets 5 mm or greater;

(II) D4342 is allowed for quadrants with at least two teeth with pocket depths of 5 mm or greater;

(v) Prior authorization for more frequent scaling and root planing may be requested when:

(I) Medically/dentally necessary due to periodontal disease as defined above is found during pregnancy; and

(II) Client’s medical record is submitted that supports the need for increased scaling and root planing;

(B) Full mouth debridement (D4355):

(i) For clients through age 20, allowed only once every 2 years;

(ii) For clients age 21 and older, allowed once every three years;

(c) Periodontal maintenance (D4910):

(A) For clients through age 20, allowed once every six months;

(B) For clients age 21 and older:

(i) Limited to following periodontal therapy (surgical or non-surgical) that is documented to have occurred within the past three years;

(ii) Allowed once every twelve months;

(iii) Prior authorization for more frequent periodontal maintenance may be requested when:

(I) Medically/dentally necessary, such as due to presence of periodontal disease during pregnancy; and

(II) Client’s medical record is submitted that supports the need for increase periodontal maintenance (chart notes, pocket depths and radiographs);

(d) Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth charting and/or radiographs;

(e) The Division may not reimburse for procedures identified by the following codes if performed on the same date of service:

(A) D1110 (Prophylaxis-adult);

(B) D1120 (Prophylaxis-child);

(C) D4210 (Gingivectomy or gingivoplasty-four or more contiguous teeth or bounded teeth spaces per quadrant);

(D) D4211 (Gingivectomy or gingivoplasty-one to three contiguous teeth or bounded teeth spaces per quadrant);

(E) D4341 (Periodontal scaling and root planning-four or more teeth per quadrant);

(F) D4342 (Periodontal scaling and root planning-one to three teeth per quadrant);

(G) D4355 (Full mouth debridement to enable comprehensive evaluation and diagnosis); and

(H) D4910 (Periodontal maintenance).

(7) REMOVABLE PROSTHODONTIC SERVICES:

(a) Clients age 16 years and older are eligible for removable resin base partial dentures (D5211-D5212) and full dentures (complete or immediate, D5110-D5140);

(b) The Division limits full dentures for clients age 21 and older to only those clients who are recently edentulous:

(A) For the purposes of this rule:

(i) “Edentulous” means all teeth removed from the jaw for which the denture is being provided; and

(ii) “Recently edentulous” means the most recent extractions from that jaw occurred within six months of the delivery of the final denture (or, for fabricated prosthetics, the final impression) for that jaw;

(B) See OAR 410-123-1000 for detail regarding billing fabricated prosthetics;

(c) The fee for the partial and full dentures includes payment for adjustments during the six-month period following delivery to clients;

(d) Resin partial dentures (D5211-D5212):

(A) The Division may not approve resin partial dentures if stainless steel crowns are used as abutments;

(B) For clients through age 20, the client must have one or more anterior teeth missing or four or more missing posterior teeth per arch with resulting space equivalent to that loss demonstrating inability to masticate. Third molars are not a consideration when counting missing teeth;

(C) For clients age 21 and older, the client must have one or more missing anterior teeth or six or more missing posterior teeth per arch with documentation by the provider of resulting space causing serious impairment to mastication. Third molars are not a consideration when counting missing teeth;

(D) The dental practitioner must note the teeth to be replaced and teeth to be clasped when requesting prior authorization (PA);

(e) Replacement of removable partial or full dentures, when it cannot be made clinically serviceable by a less costly procedure (e.g., reline, rebase, repair, tooth replacement), is limited to the following:

(A) For clients at least 16 years and under 21 years of age - the Division shall replace full or partial dentures once every ten years, only if dentally appropriate. This does not imply that replacement of dentures or partials must be done once every ten years, but only when dentally appropriate;

(B) For clients 21 years of age and older - the Division may not cover replacement of full dentures, but shall cover replacement of partial dentures once every 10 years only if dentally appropriate;

(C) The ten year limitations apply to the client regardless of the client’s OHP or Dental Care Organization (DCO)/Coordinated Care Organization (CCO) enrollment status at the time client’s last denture or partial was received. For example: a client receives a partial on February 1, 2002, and becomes a FFS OHP client in 2005. The client is not eligible for a replacement partial until February 1, 2012. The client gets a replacement partial on February 3, 2012 while FFS and a year later enrolls in a DCO, CCO. The client would not be eligible for another partial until February 3, 2022, regardless of DCO, CCO or FFS enrollment;

(D) Replacement of partial dentures with full dentures is payable ten years after the partial denture placement. Exceptions to this limitation may be made in cases of acute trauma or catastrophic illness that directly or indirectly affects the oral condition and results in additional tooth loss. This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical and/or medical treatment for aforementioned conditions. Severe periodontal disease due to neglect of daily oral hygiene may not warrant replacement;

(f) The Division limits reimbursement of adjustments and repairs of dentures that are needed beyond six months after delivery of the denture as follows for clients 21 years of age and older:

(A) A maximum of 4 times per year for:

(i) Adjusting complete and partial dentures, per arch (D5410-D5422);

(ii) Replacing missing or broken teeth on a complete denture-each tooth (D5520);

(iii) Replacing broken tooth on a partial denture-each tooth (D5640);

(iv) Adding tooth to existing partial denture (D5650);

(B) A maximum of 2 times per year for:

(i) Repairing broken complete denture base (D5510);

(ii) Repairing partial resin denture base (D5610);

(iii) Repairing partial cast framework (D5620);

(iv) Repairing or replacing broken clasp (D5630);

(v) Adding clasp to existing partial denture (D5660);

(g) Replacement of all teeth and acrylic on cast metal framework (D5670D5671):

(A) Is covered for clients age 16 and older a maximum of once every 10 years, per arch;

(B) Ten years or more must have passed since the original partial denture was delivered;

(C) Is considered replacement of the partial so a new partial denture may not be reimbursed for another 10 years; and

(D) Requires prior authorization as it is considered a replacement partial denture;

(h) Denture rebase procedures:

(A) The Division shall cover rebases only if a reline may not adequately solve the problem;

(B) For clients through age 20, the Division limits payment for rebase to once every three years;

(C) For clients age 21 and older:

(i) There must be documentation of a current reline which has been done and failed; and

(ii) The Division limits payment for rebase to once every five years;

(D) The Division may make exceptions to this limitation in cases of acute trauma or catastrophic illness that directly or indirectly affects the oral condition and results in additional tooth loss. This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical and medical treatment for aforementioned conditions. Severe periodontal disease due to neglect of daily oral hygiene may not warrant rebasing;

(i) Denture reline procedures:

(A) For clients through age 20, the Division limits payment for reline of complete or partial dentures to once every three years;

(B) For clients age 21 and older, the Division limits payment for reline of complete or partial dentures to once every five years;

(C) The Division may make exceptions to this limitation under the same conditions warranting replacement;

(D) Laboratory relines:

(i) Are not payable prior to six months after placement of an immediate denture; and

(ii) For clients through age 20, are limited to once every three years;

(iii) For clients age 21 and older, are limited to once every five years;

(j) Interim partial dentures (D5820-D5821, also referred to as “flippers”):

(A) Are allowed if the client has one or more anterior teeth missing; and

(B) The Division shall reimburse for replacement of interim partial dentures once every 5 years, but only when dentally appropriate;

(k) Tissue conditioning:

(A) Is allowed once per denture unit in conjunction with immediate dentures; and

(B) Is allowed once prior to new prosthetic placement.

(8) MAXILLOFACIAL PROSTHETIC SERVICES:

(a) Fluoride gel carrier (D5986) is limited to those patients whose severity of oral disease causes the increased cleaning and fluoride treatments allowed in rule to be insufficient. The dental practitioner must document failure of those options prior to use of the fluoride gel carrier;

(b) All other maxillofacial prosthetics (D5900-D5999) are medical services. Refer to the “Covered and Non-Covered Dental Services” document and OAR 410-123-1220:

(A) Bill for medical maxillofacial prosthetics using the professional (CMS1500, DMAP 505 or 837P) claim format:

(B) For clients receiving services through a CCO or PHP, bill medical maxillofacial prosthetics to the CCO or PHP;

(C) For clients receiving medical services through FFS, bill the Division.

(9) ORAL SURGERY SERVICES:

(a) Bill the following procedures in an accepted dental claim format using CDT codes:

(A) Procedures that are directly related to the teeth and supporting structures that are not due to a medical, including such procedures performed in an ambulatory surgical center (ASC) or an inpatient or outpatient hospital setting;

(B) Services performed in a dental office setting (including an oral surgeon’s office):

(i) Such services include, but are not limited to, all dental procedures, local anesthesia, surgical postoperative care, radiographs and follow-up visits;

(ii) Refer to OAR 410-123-1160 for any PA requirements for specific procedures;

(b) Bill the following procedures using the professional claim format and the appropriate American Medical Association (AMA) CPT procedure and ICD9 diagnosis codes:

(A) Procedures that are a result of a medical condition (i.e., fractures, cancer);

(B) Services requiring hospital dentistry that are the result of a medical condition/diagnosis (i.e., fracture, cancer);

(c) Refer to the “Covered and Non-Covered Dental Services” document to see a list of CDT procedure codes on the Prioritized List that may also have CPT medical codes. See OAR 410-123-1220. The procedures listed as “medical” on the table may be covered as medical procedures, and the table may not be all-inclusive of every dental code that has a corresponding medical code;

(d) For clients enrolled in a DCO or CCO responsible for dental services, the DCO, CCO shall pay for those services in the dental plan package;

(e) Oral surgical services performed in an ASC or an inpatient or outpatient hospital setting:

(A) Require PA;

(B) For clients enrolled in a CCO or FCHP, the CCO or FCHP shall pay for the facility charge and anesthesia services. For clients enrolled in a Physician Care Organization (PCO), the PCO shall pay for the outpatient facility charge (including ASCs) and anesthesia. Refer to the current Medical Surgical Services administrative rules in OAR chapter 410, division 130 for more information;

(C) If a client is enrolled in a CCO or PHP, the provider must contact the CCO or PHP for any required authorization before the service is rendered;

(f) All codes listed as “by report” require an operative report;

(g) The Division covers payment for tooth re-implantation only in cases of traumatic avulsion where there are good indications of success;

(h) Biopsies collected are reimbursed as a dental service. Laboratory services of biopsies are reimbursed as a medical service;

(i) The Division does not cover surgical excisions of soft tissue lesions (D7410-D7415);

(j) Extractions-Includes local anesthesia and routine postoperative care, including treatment of a dry socket if done by the provider of the extraction. Dry socket is not considered a separate service;

(k) Surgical extractions:

(A) Include local anesthesia and routine post-operative care;

(B) The Division limits payment for surgical removal of impacted teeth or removal of residual tooth roots to treatment for only those teeth that have acute infection or abscess, severe tooth pain, and/or unusual swelling of the face or gums;

(C) The Division does not cover alveoloplasty in conjunction with extractions (D7310 and D7311) separately from the extraction;

(D) The Division covers alveoloplasty not in conjunction with extractions (D7320-D7321) only for clients under 21 years of age or who are pregnant;

(l) Frenulectomy/frenulotomy (D7960) and frenuloplasty (D7963):

(A) The Division covers either frenulectomy or frenuloplasty once per lifetime per arch only for clients under age 21;

(B) The Division covers maxillary labial frenulectomy only for clients age 12 through 20;

(C) The Division shall cover frenulectomy/frenuloplasty in the following situations:

(i) When the client has ankyloglossia;

(ii) When the condition is deemed to cause gingival recession; or

(iii) When the condition is deemed to cause movement of the gingival margin when the frenum is placed under tension;

(m) The Division covers excision of pericoronal gingival (D7971) only for clients under age 21 or who are pregnant.

(10) ORTHODONTIA SERVICES:

(a) The Division limits orthodontia services and extractions to eligible clients:

(A) With the ICD-9-CM diagnosis of:

(i) Cleft palate; or

(ii) Cleft palate with cleft lip; and

(B) Whose orthodontia treatment began prior to 21 years of age; or

(C) Whose surgical corrections of cleft palate or cleft lip were not completed prior to age 21;

(b) PA is required for orthodontia exams and records. A referral letter from a physician or dentist indicating diagnosis of cleft palate or cleft lip must be included in the client’s record and a copy sent with the PA request;

(c) Documentation in the client’s record must include diagnosis, length and type of treatment;

(d) Payment for appliance therapy includes the appliance and all follow-up visits;

(e) Orthodontists evaluate orthodontia treatment for cleft palate/cleft lip as two phases. Stage one is generally the use of an activator (palatal expander) and stage two is generally the placement of fixed appliances (banding). The Division shall reimburse each phase separately;

(f) The Division shall pay for orthodontia in one lump sum at the beginning of each phase of treatment. Payment for each phase is for all orthodontia-related services. If the client transfers to another orthodontist during treatment, or treatment is terminated for any reason, the orthodontist must refund to the Division any unused amount of payment, after applying the following formula: Total payment minus $300.00 (for banding) multiplied by the percentage of treatment remaining;

(g) The Division shall use the length of the treatment plan from the original request for authorization to determine the number of treatment months remaining;

(h) As long as the orthodontist continues treatment, the Division may not require a refund even though the client may become ineligible for medical assistance sometime during the treatment period;

(i) Code:

(A) D8660-PA required (reimbursement for required orthodontia records is included);

(B) Codes D8010-D8690-PA required.

(11) ADJUNCTIVE GENERAL AND OTHER SERVICES:

(a) Fixed partial denture sectioning (D9120) is covered only when extracting a tooth connected to a fixed prosthesis and a portion of the fixed prosthesis is to remain intact and serviceable, preventing the need for more costly treatment;

(b) Anesthesia:

(A) Only use general anesthesia or IV sedation for those clients with concurrent needs: age, physical, medical or mental status, or degree of difficulty of the procedure (D9220, D9221, D9241 and D9242);

(B) The Division reimburses providers for general anesthesia or IV sedation as follows:

(i) D9220 or D9241: For the first 30 minutes;

(ii) D9221 or D9242: For each additional 15-minute period, up to three hours on the same day of service. Each 15-minute period represents a quantity of one. Enter this number in the quantity column;

(C) The Division reimburses administration of Nitrous Oxide (D9230) per date of service, not by time;

(D) Oral pre-medication anesthesia for conscious sedation (D9248):

(i) Limited to clients under 13 years of age;

(ii) Limited to four times per year;

(iii) Includes payment for monitoring and Nitrous Oxide; and

(iv) Requires use of multiple agents to receive payment;

(E) Upon request, providers must submit a copy of their permit to administer anesthesia, analgesia and sedation to the Division;

(F) For the purpose of Title XIX and Title XXI, the Division limits payment for code D9630 to those oral medications used during a procedure and is not intended for “take home” medication;

(c) The Division limits reimbursement of house/extended care facility call (D9410) only for urgent or emergent dental visits that occur outside of a dental office. This code is not reimbursable for provision of preventive services or for services provided outside of the office for the provider or facilities’ convenience;

(d) Oral devices/appliances (E0485, E0486):

(A) These may be placed or fabricated by a dentist or oral surgeon, but are considered a medical service;

(B) Bill the Division, CCO or the PHP for these codes using the professional claim format.

Stat. Auth.: ORS 413.042, 414.065 & 414.707

Stats. Implemented: ORS 414.065 & 414.707

Hist.: HR 3-1994, f. & cert. ef. 2-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; OMAP 55-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 12-2005, f. 3-11-05, cert. ef. 4-1-05; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 18-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 17-2011, f. & cert. ef. 7-12-11; DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 28-2013(Temp), f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13; DMAP 68-2013, f. 12-5-13, cert. ef. 12-23-13

Notes
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