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Oregon Bulletin

May 1, 2011

Oregon Health Authority,
Division of Medical Assistance Programs
Chapter 410

  • Rule Caption: Public safety and medical appropriateness for speech augmentation systems/devices and durable medical equipment.
  • Adm. Order No.: DMAP 3-2011
  • Filed with Sec. of State: 3-23-2011
  • Certified to be Effective: 3-25-11
  • Notice Publication Date: 2-1-2011
  • Rules Amended: 410-122-0080, 410-122-0180, 410-129-0220
  • Rules Repealed: 410-122-0080(T), 410-122-0180(T), 410-129-0220(T)
  • Subject: The Durable Medical Equipment, Prosthetics, Orthotics and Supplies Services Program and the Speech-language pathology, Audiology and Hearing Aid Services Program administrative rules govern the Division’s payment for services to certain clients. Having temporarily amended rules listed above, the Division permanently amended the rules to provide clarity of coverage, ensure client safety, and ensure medically appropriate devices are provided. These amendments assist clients, speech therapists, and other providers of equipment to have clear and precise knowledge of prescription and medical appropriateness requirements for Speech Augmentative Communication Systems and Devices acquired through the Oregon Health Plan.
  •       Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.
  • Rules Coordinator: Darlene Nelson—(503) 945-6927
  •  
  • 410-122-0080
  • Conditions of Coverage, Limitations, Restrictions and Exclusions
  • (1) The Division of Medical Assistance Programs (Division) may pay for durable medical equipment, prosthetics, orthotics and medical supplies (DMEPOS) when the item meets all the criteria in this rule, including all of the following conditions. The item:
  • (a) Has been approved for marketing and registered or listed as a medical device by the Food and Drug Administration (FDA) and is otherwise generally considered to be safe and effective for the purpose intended. In the event of delay in FDA approval and registration, the Division will review purchase options on a case by case basis;
  • (b) Is reasonable and medically appropriate for the individual client;
  • (c) Is primarily and customarily used to serve a medical purpose;
  • (d) Is generally not useful to a person in the absence of illness or injury;
  • (e) Is appropriate for use in a client’s home;
  • (f) Specifically, for durable medical equipment, can withstand repeated use; i.e., could normally be rented, and used by successive clients;
  • (g) Meets the coverage criteria as specified in this division and subject to service limitations of the Division rules;
  • (h) Is requested in relation to a diagnosis and treatment pair that is above the funding line on the Oregon Health Services Commission’s Prioritized List of Health Services (Prioritized List of Health Services or List) found in OAR 410-141-0520, consistent with treatment guidelines for the Prioritized List of Health Services, and not otherwise excluded under OAR 410-141-0500; and
  • (i) Is included in the Oregon Health Plan (OHP) client’s benefit package of covered services.
  • (2) Conditions for Medicare-Medicaid Services:
  • (a) If Medicare is the primary payer and Medicare denies payment, an appeal to Medicare must be filed timely prior to submitting the claim to the Division for payment. If Medicare denies payment based on failure to submit a timely appeal, the Division may reduce any amount the Division determines could have been paid by Medicare;
  • (b) If Medicare denies payment on appeal, the Division will apply DMEPOS coverage criteria in this rule to determine whether the item or service is covered under the OHP.
  • (3) The Division will not cover DMEPOS items when the item or the use of the item is:
  • (a) Not primarily medical in nature;
  • (b) For personal comfort or convenience of client or caregiver;
  • (c) A self-help device;
  • (d) Not therapeutic or diagnostic in nature;
  • (e) Used for precautionary reasons (e.g., pressure-reducing support surface for prevention of decubitus ulcers);
  • (f) Inappropriate for client use in the home (e.g., institutional equipment like an oscillating bed);
  • (g) For a purpose where the medical effectiveness is not supported by evidence-based clinical practice guidelines; or
  • (h) Reimbursed as part of the all-inclusive rate in a nursing facility, or as part of a home and community based care waiver service, or by any other public, community or third party resource.
  • (4) In addition to the particular requirements in this rule, particular coverage criteria, limitations and restrictions for durable medical equipment, prosthetics, orthotics and supplies are specified in the appropriate rule. To the extent that codes are identified in these rules or in fee schedules, the codes are provided as a mechanism to facilitate payment for covered items and supplies consistent with OAR 410-122-0186, but codes do not determine coverage. If prior authorization is required, the request must document that prior authorization was obtained in compliance with the rules in this division.
  • (5) DMEPOS providers must have documentation on file that supports coverage criteria are met.
  • (6) Billing records must demonstrate that the provider has not exceeded any limitations and restrictions in rule. The Division may require additional claim information from the provider consistent with program integrity review processes.
  • (7) Documentation described in (4), (5) and (6) above must be made available to the Division on request.
  • (8) To identify non-covered items at a code level, providers can refer to the Division fee schedule, subject to the limitation that fee schedules and codes do not determine coverage, and are solely provided as a mechanism to facilitate payment for covered services and supplies consistent with OAR 410-122-0186. If an item or supply is not covered for an OHP client in accordance with these rules, there is no basis for payment regardless of whether there is a code for the item or supply on the fee schedule.
  • (9) Some benefit packages do not cover equipment and supplies (see OAR 410-120-1210 Medical Assistance Benefit Packages and Delivery System).
  • (10) Buy-ups are prohibited. Advanced Beneficiary Notices (ABN) constitutes a buy-up and are prohibited. Refer to the Division General Rules (chapter 410, division 120) for specific language on buy-ups.
  • (11) Equipment purchased by the Division for a client is the property of the client.
  • (12) Rental charges, starting with the initial date of service, regardless of payer, apply to the purchase price.
  • (13) A provider who supplies rented equipment is to continue furnishing the same item throughout the entire rental period, except under documented reasonable circumstances.
  • (14) Before renting, providers should consider purchase for long-term requirements.
  • (15) The Division will not pay DMEPOS providers for medical supplies separately while a client is under a home health plan of care and covered home health care services.
  • (16) The Division will not pay DMEPOS providers for medical supplies separately while a client is under a hospice plan of care where the supplies are included as part of the written plan of care and for which payment may otherwise be made by Medicare, the Division or other carrier.
  • (17) Separate payment will not be made to DMEPOS providers for equipment and medical supplies provided to a client in their home when the cost of such items is already included in the capitated (per diem) rate paid to a facility or organization.
  • (18) Non-contiguous out-of-state DMEPOS providers may seek Medicaid payment only under the following circumstances:
  • (a) Medicare/Medicaid clients:
  • (A) For Medicare covered services and then only Medicaid payment of a client’s Medicare cost sharing expenses for DMEPOS services when all of the following criteria are met:
  • (i) Client is a qualified Medicare beneficiary;
  • (ii) Service is covered by Medicare;
  • (iii) Medicare has paid on the specific code. Prior authorization is not required;
  • (B) Services not covered by Medicare:
  • (i) Only when the service or item is not available in the State of Oregon and this is clearly substantiated by supporting documentation from the prescribing practitioner and maintained in the DMEPOS provider’s records;
  • (ii) Some examples of services not reimbursable to a non-contiguous out of-state provider are incontinence supplies, grab bars, etc. This list is not all-inclusive;
  • (iii) Services billed must be covered under the OHP;
  • (iv) Services provided and billed to the Division must be in accordance with all applicable Division rules;
  • (b) Medicaid-only clients:
  • (A) For a specific Oregon Medicaid client who is temporarily outside Oregon or the contiguous borders of Oregon and only when the prescribing practitioner has documented that a delay in service may cause client harm;
  • (B) For foster care or subsidized adoption children placed out of state;
  • (C) Only when the service or item is not available in the State of Oregon and this is clearly substantiated by supporting documentation from the prescribing practitioner and maintained in the DMEPOS provider’s records;
  • (D) Services billed must be covered under the OHP;
  • (E) Services provided and billed to the Division must be in accordance with all applicable DMAP rules.
  • (19) The items listed in Table 122-0080 generally do not meet the requirements under DMEPOS rules for purchase, rent or repair of equipment or items. A request for equipment or an item on this list will not be granted.
  • (20) See General Rules OAR 410-120-1200 Excluded Services and Limitations for more information on general scope of coverage and limitations.
  • (21) Table 122-0080, Exclusions. [Table not included. See ED. NOTE.]
  • [ED. NOTE: Tables referenced are available from the agency.]
  • Stat. Auth.: ORS 413.042 & 414.065
  • Stats. Implemented: ORS 413.042 & 414.065
  • Hist.: AFS 3-1982, f. 1-20-82, ef. 2-1-82; AFS 6-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 24-1990(Temp), f. & cert. ef. 7-27-90; HR 6-1991, f. & cert. ef. 1-18-91, Renumbered from 461-024-0020; HR 10-1992, f. & cert. ef. 4-1-92; HR 9-1993 f. & cert. ef. 4-1-93; HR 26-1994, f. & cert. ef. 7-1-94; HR 17-1996, f. & cert. ef. 8-1-96; HR 7-1997, f. 2-28-97, cert. ef. 3-1-97; OMAP 11-1998, f. & cert. ef. 4-1-98; OMAP 13-1999, f. & cert. ef. 4-1-99; OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 25-2004, f. & cert. ef. 4-1-04; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 46-2004, f. 7-22-04 cert. ef. 8-1-04; OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06; OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07; DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 15-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 26-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11; DMAP 28-2010(Temp), f. & cert. ef. 10-7-10 thru 3-25-11; DMAP 29-2010(Temp), f. & cert. ef. 10-13-10 thru 3-25-11; DMAP 3-2011, f. 3-23-11, cert. ef. 3-25-11
  •  
  • 410-122-0180
  • Healthcare Common Procedure Coding System Level II Coding
  • (1) The Healthcare Common Procedure Coding System (HCPCS) level II is a comprehensive and standardized system that classifies similar products that are medical in nature into categories for the purpose of efficient claims processing. For each alphanumeric HCPCS code, there is descriptive terminology that identifies a category of like items. These codes are used primarily for billing purposes. The Centers for Medicare and Medicaid Services (CMS) maintain and distribute HCPCS Level II Codes.
  • (2) HCPCS is a system for identifying items and services. It is not a methodology or system for making coverage or payment determinations. The existence of a code does not, of itself, determine coverage for an item or service. While these codes are used for billing purposes, decisions regarding the addition, deletion, or revision of HCPCS codes are made independently of the process for making coverage and payment determinations for medical items or services. Items billed that do not have a HCPCS code will be reviewed by the Division of Medical Assistance Programs (Division) on a case by case basis to ensure rule 410-122-0080 is appropriately applied to item billed.
  • (3) The Division uses the HCPCS Level II Code Set to ensure that claims are processed in an orderly and consistent manner.
  • (4) When requesting authorization and submitting claims, DMEPOS providers must use these codes to identify the items they are billing. The descriptor that is assigned to a code represents the definition of the items and services that can be billed using that code.
  • (5) This rule division may not contain all code updates needed to report medical services and supplies.
  • (6) For the most up-to-date information on code additions, changes, or deletions, refer to the fee schedule posted on the Division Web site.
  • (7) The Division fee schedule lists all of the current HCPCS codes in an alphanumeric index.
  • (8) Newly established temporary codes and effective dates for their use are also posted on the Division website at www.oregon.gov/DHS/healthplan/data_pubs/feeschedule/main.shtml.
  • (9) CMS updates permanent national codes annually on January 1st.
  • (10) CMS may add, change, or delete temporary national codes on a quarterly basis.
  • (11) The Medicare Pricing, Data Analysis and Coding (PDAC) contractor is responsible for assisting DMEPOS providers and manufacturers in determining which HCPCS code should be used to describe DMEPOS items.
  • [Publications: Publications referenced are available from the agency.]
  • Stat. Auth.: ORS 413.042 & 414.065
  • Stats. Implemented: ORS 413.042 & 414.065
  • Hist.: AFS 6-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 7-1990, f. 3-30-89, cert. ef. 4-1-89, Renumbered from 461-024-0200; HR 13-1991, f. & cert. ef. 3-1-91, Renumbered from 410-122-0100; HR 10-1992, f. & cert. ef. 4-1-92; HR 9-1993 f. & cert. ef. 4-1-93; HR 10-1994, f. & cert. ef. 2-15-94; HR 26-1994, f. & cert. ef. 7-1-94; HR 41-1994, f. 12-30-94, cert. ef. 1-1-95; HR 17-1996, f. & cert. ef. 8-1-96; OMAP 11-1998, f. & cert. ef. 4-1-98; OMAP 12-1999(Temp), f. & cert. ef. 4-1-99 thru 9-1-99; OMAP 26-1999, f. & cert. ef. 6-4-99; OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 54-2001(Temp), f. 10-31-01, cert. ef. 11-1-01 thru 4-15-02; OMAP 63-2001, f. 12-28-01, cert. ef. 1-1-02; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 25-2004, f. & cert. ef. 4-1-04; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 15-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 26-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11; DMAP 3-2011, f. 3-23-11, cert. ef. 3-25-11
  •  
  • 410-129-0220
  • Augmentative Communications System or Device
  • (1) Augmentative Communications System or Device and the necessary attachment equipment to bed or wheelchair are a covered benefit of the Division of Medical Assistance Programs (Division).
  • (2) The requested system or device must be approved, registered or listed as a medical device with the Food and Drug Administration.
  • (3) Criteria for coverage: Providers must meet each of the following components and submit documentation to the Division with the prior authorization request for review:
  • (a) A physician’s statement of diagnosis and medical prognosis (not a prescription for an augmentative device) documenting the inability to use speech for effective communication as a result of the diagnosis;
  • (b) The client must have reliable cognitive ability and a consistent motor response to communicate that can be measured by standardized or observational tools:
  • (A) Object permanence — ability to remember objects and realize they exist when they are not seen; and
  • (B) Means end — ability to anticipate events independent of those currently in progress — the ability to associate certain behaviors with actions that will follow;
  • (c) The client must be assessed by a Speech Pathologist and when appropriate an Occupational Therapist and/or Physical Therapist. The evaluation report(s) must include:
  • (A) A completed DMAP 3047 form: Augmentative Communication Device Selection Report Summary (page 1) and required elements of the Formal Augmentative/Alternative Communication Evaluation (page 2). Attach additional pages required to complete information requested;
  • (B) An explanation of why this particular device is best suited for this client and why the device is the lowest level that will meet basic functional communication needs;
  • (C) Evidence of a documented trial of the selected device and a report on the client’s success in using this device; and
  • (D) A therapy treatment plan with the identification of the individual responsible to program the device, monitor and reevaluate on a periodic basis;
  • (d) Providers send requests for augmentative communications systems or devices to the Division; and
  • (e) The manufacturer’s MSRP and the vendor’s acquisition cost quotations for the device must accompany each request including where the device is to be shipped.
  • (4) The Division shall reimburse for the lowest level of service that meets the medical need.
  • Stat. Auth.: ORS 413.042
  • Stats. Implemented: ORS 413.042 & 414.065
  • Hist.: HR 40-1990(Temp), f. & cert. ef. 11-15-90; HR 5-1991, f. 1-18-91, cert. ef. 2-1-91; HR 11-1992, f. & cert. ef. 4-1-92; HR 36-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 36-1999, f. & cert. ef. 10-1-99; OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 59-2003, f. 9-5-03, cert. ef. 10-1-03; DMAP 26-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11; DMAP 3-2011, f. 3-23-11, cert. ef. 3-25-11
  •  
  • Rule Caption: April 2011 Technical changes to the January 1, 2011–December 31, 2012 Health Services Commission’s Prioritized List of Health Services.
  • Adm. Order No.: DMAP 4-2011
  • Filed with Sec. of State: 3-23-2011
  • Certified to be Effective: 4-1-11
  • Notice Publication Date: 3-1-2011
  • Rules Amended: 410-141-0520
  • Subject: The Oregon Health Plan (OHP or Managed Care) program administrative rules govern Division of Medical Assistance Programs’ (DMAP) payment for services to certain clients. DMAP permanently amended 410-141-0520 to reference the January 1, 2010–December 31, 2011 Health Services Commission’s Prioritized List with interim modifications and technical changes effective April 1, 2010, including application of 2009 national code to the HSC lines and HSC guideline refinements.
  • Rules Coordinator: Darlene Nelson—(503) 945-6927
  •  
  • 410-141-0520
  • Prioritized List of Health Services
  • (1) The Prioritized List of Health Services (Prioritized List) is the Oregon Health Services Commission’s (HSC) listing of physical health services with “expanded definitions” of preventive services and the HSC’s practice guidelines, as presented to the Oregon Legislative Assembly. The Prioritized List is generated and maintained by HSC. The HSC maintains the most current list on the HSC website: www.oregon.gov/DHS/healthplan/priorlist/main, or, for a hardcopy contact the Office for Oregon Health Policy and Research. This rule incorporates to reference the CMS approved biennial January 1, 2011–December 31, 2012 Prioritized List, including interim modifications and technical revisions made for the 2009 national code set effective April 1, 2011 that includes expanded definitions, practice guidelines and condition treatment pairs funded through line 502.
  • (2) Certain mental health services are only covered for payment when provided by a Mental Health Organization (MHO), Community Mental Health Program (CMHP) or authorized Fully Capitated Health Plan (FCHP) or Physician Care Organization (PCO). These codes are identified on their own Mental Health (MH) section of the appropriate lines on the Prioritized List of Health Services.
  • (3) Chemical dependency (CD) services are covered for eligible OHP clients when provided by an FCHP, PCO, or by a provider who has a letter of approval from the Office of Addictions and Mental Health and approval to bill Medicaid for CD services.
  • Stat. Auth.: ORS 192.527, 192.528, 413.042 & 414.065
  • Stats. Implemented: ORS 192.527, 192.528, 414.065 & 414.727
  • Hist.: HR 7-1994, f. & cert. ef. 2-1-94; OMAP 33-1998, f. & cert. ef. 9-1-98; OMAP 40-1998(Temp), f. & cert. ef. 10-1-98 thru 3-1-99; OMAP 48-1998(Temp), f. & cert. ef. 12-1-98 thru 5-1-99; OMAP 21-1999, f. & cert. ef. 4-1-99; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 9-2000(Temp), f. 4-27-00, cert. ef. 4-27-00 thru 9-26-00; OMAP 13-2000, f. & cert. ef. 9-12-00; OMAP 14-2000(Temp), f. 9-15-00, cert. ef. 10-1-00 thru 3-30-01; OMAP 40-2000, f. 11-17-00, cert. ef. 11-20-00; OMAP 22-2001(Temp), f. 3-30-01, cert. ef. 4-1-01 thru 9-1-01; OMAP 28-2001, f. & cert. ef. 8-10-01; OMAP 53-2001, f. & cert. ef. 10-1-01; OMAP 18-2002, f. 4-15-02, cert. ef. 5-1-02; OMAP 64-2002, f. & cert. ef. f. & cert. ef. 10-2-02; OMAP 65-2002(Temp), f. & cert. ef. 10-2-02 thru 3-15-0; OMAP 88-2002, f. 12-24-02, cert. ef. 1-1-03; OMAP 14-2003, f. 2-28-03, cert. ef. 3-1-03; OMAP 30-2003, f. 3-31-03 cert. ef. 4-1-03; OMAP 79-2003(Temp), f. & cert. ef. 10-2-03 thru 3-15-04; OMAP 81-2003(Temp), f. & cert. ef. 10-23-03 thru 3-15-04; OMAP 94-2003, f. 12-31-03 cert. ef. 1-1-04; OMAP 17-2004(Temp), f. 3-15-04 cert. ef. 4-1-04 thru 9-15-04; OMAP 28-2004, f. 4-22-04 cert. ef. 5-1-04; OMAP 48-2004, f. 7-28-04 cert. ef. 8-1-04; OMAP 51-2004, f. 9-9-04, cert. ef. 10-1-04; OMAP 68-2004(Temp), f. 9-14-04, cert. ef. 10-1-04 thru 3-15-05; OMAP 83-2004, f. 10-29-04 cert. ef. 11-1-04; OMAP 27-2005, f. 4-20-05, cert. ef. 5-1-05; OMAP 54-2005(Temp), f. & cert. ef. 10-14-05 thru 4-1-06; OMAP 62-2005, f. 11-29-05, cert. ef. 12-1-05; OMAP 71-2005, f. 12-21-05, cert. ef. 1-1-06; OMAP 6-2006, f. 3-22-06, cert. ef. 4-1-06; OMAP 46-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 14-2007(Temp), f. & cert. ef. 10-1-07 thru 3-28-08; DMAP 28-2007(Temp), f. & cert. ef. 12-20-07 thru 3-28-08; DMAP 8-2008, f & cert. ef. 3-27-08; DMAP 10-2008(Temp), f. & cert. ef. 4-1-08 thru 9-15-08; DMAP 23-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 31-2008(Temp), f. & cert. ef. 10-1-08 thru 3-29-09; DMAP 40-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 4-2009(Temp), f. & cert. ef. 1-30-09 thru 6-25-09; DMAP 6-2009(Temp), f. 3-26-09, cert. ef. 4-1-09 thru 9-25-09; DMAP 8-2009(Temp), f. & cert. ef. 4-17-09 thru 9-25-09; DMAP 26-2009, f. 8-3-09, cert. ef. 8-5-09; DMAP 30-2009(Temp), f. 9-15-09, cert. ef. 10-1-09 thru 3-29-10; DMAP 36-2009(Temp), f. 12-10-09 ef. 1-1-10 thru 3-29-10; DMAP 1-2010(Temp), f. & cert. ef. 1-15-10 thru 3-29-10; DMAP 3-2010, f. 3-5-10, cert. ef. 3-17-10; DMAP 5-2010(Temp), f. 3-26-10, cert. ef. 4-1-10 thru 9-1-10; DMAP 10-2010, f. & cert. ef. 4-26-10; DMAP 27-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11; DMAP 43-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 4-2011, f. 3-23-11, cert. ef. 4-1-11
  •  
  • Rule Caption: CAREAssist rules and provider payments.
  • Adm. Order No.: DMAP 5-2011
  • Filed with Sec. of State: 3-29-2011
  • Certified to be Effective: 3-29-11
  • Notice Publication Date: 3-1-2011
  • Rules Ren. & Amend: 333-012-0250 to 410-121-3000
  • Subject: The Oregon Health Authority is permanently amending OAR 333-012-0250 and renumbering it to OAR 410-121-3000 pertaining to the AIDS Drugs Assistance Program (ADAP) or CAREAssist. The rule is being amended to include a section regarding provider and pharmacy payments. The rule is being renumbered from chapter 333 (Public Health Division) to chapter 410 (Division of Medical Assistance Programs) so that all pharmacy rules (Medicaid and non-Medicaid) for the Oregon Health Authority are found in the same location.
  • Rules Coordinator: Brittany Sande—(917) 673-1291
  •  
  • 410-121-3000
  • AIDS Drug Assistance Program
  • (1) Purpose. The AIDS Drug Assistance Program (ADAP) provides medications for the treatment of HIV disease. The program is primarily funded through Part B of the Ryan White Treatment Modernization Act, which provides grants to states and territories. The Oregon Health Authority shall administer the federal funds awarded under Part B of the Ryan White Treatment Modernization Act for the State of Oregon.
  • (2) Services. Program funds may be used to provide access to medication, purchase health insurance for eligible clients and services that enhance access, adherence, and monitoring of drug treatments.
  • (3) Eligibility: Individuals must provide documentation of a HIV diagnosis and meet income and resource guidelines as set by the Oregon Health Authority and other criteria as defined in the Ryan White Treatment Modernization Act.
  • (4) This program shall be in effect as long as authorized funds are available.
  • (5) Provider Payments: CAREAssist will make payments to providers for medical services provided to CAREAssist and Bridge clients to the extent funds are available. Payments made by CAREAssist on behalf of its clients must be accepted by the provider as full payment for the services provided.
  • (a) CAREAssist as the last payer: Before a provider bills CAREAssist for medical services provided to CAREAssist clients, all other insurance(s) for which the client is eligible must be billed by the provider. Only the uncompensated balance, which is the portion the clients must pay, is eligible for payment under this rule.
  • (b) CAREAssist as the primary payer: If a CAREAssist client has no insurance or when these services are not covered due to a pre-existing exclusion imposed by insurance, CAREAssist will pay for out-patient service CPT codes. When CAREAssist acts as the primary provider, CAREAssist will pay providers at 125 percent of the Oregon Division of Medical Assistance Programs (Medicaid) reimbursement rate. A current fee schedule for the Oregon Division of Medical Assistance Programs can be found at http://www.oregon.gov/DHS/healthplan/data_pubs/feeschedule/
    downloads.shtml.
  • (c) For Bridge clients: For purposes of this rule, Bridge client refers to anyone enrolled in the Bridge program which provides temporary financial assistance to individuals for accessing HIV treatment while applying for long term medical insurance. CAREAssist will reimburse providers at 125 percent of the Oregon Division of Medical Assistance Programs (Medicaid) rate for a limited number of service CPT codes. A list of covered service codes available to Bridge clients can be found at www.oregon.gov/OHA/pharmacy/careassist/docs/bridgecodes.pdf
  • (6) Pharmacy Payments: The program will reimburse pharmacies on all full pay medications at [Average Wholesale Price (AWP) – 15%] + $3.50 for both single-source generics and brand drugs and [AWP – 60%] + $3.50 for generic drugs.
  • (7) The Oregon Health Authority will periodically re-evaluate the program in order to fully utilize the funds available.
  • Stat. Auth.: ORS 431.830
  • Stats. Implemented: ORS 431.830
  • Hist.: HD 14-1987(Temp), f. & ef. 9-30-87; HD 9-1988, f. 5-11-88, cert. ef. 5-12-88; HD 1-1990(Temp), f. & cert. ef. 1-8-90; PH 9-2005, f. 6-15-05, cert. ef. 6-21-05; PH 25-2010(Temp), f. & cert. ef. 10-1-10 thru 3-29-11; Renumbered from 333-012-0250 by DMAP 5-2011, f. & cert. ef. 3-29-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

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