Oregon Administrative Code

410-141-5380 CIVIL PENALTIES (1) The Director of the Oregon Health Authority may impose a civil penalty for violations of OAR 410-141-5000 to 410-141-5380 or any final order of the Authority entered under any of OAR 410-141-5000 to 410-141-5380, in an amount determined by the Aut…

410-142-0020 Definitions (1) Accredited/Accreditation: A designation by an accrediting organization that a hospice program has met standards that have been developed to indicate a quality program. (2) Ancillary staff: Staff that provides additional services to support or suppleme…

410-142-0040 Eligibility for the Hospice Services (1) Hospice services are covered for clients who have: (a) Been certified as terminally ill in accordance with OAR 410-142-0060; and (b) Have Oregon Health Plan (OHP) Plus benefit package coverage. (2) Providers must bill Medicare…

410-142-0060 Certification of Terminal Illness (1) In order to receive reimbursement from the Division of Medical Assistance Programs (Division), the hospice must obtain and retain a physician’s written certification of a client’s terminal illness in accordance with the following…

410-142-0080 Informed Consent A hospice must demonstrate respect for an individual's rights by ensuring that an informed consent form has been obtained for every individual, either from the individual or representative as defined in OAR 410-142-0020. The form must specify the typ…

410-142-0100 Election of Hospice Care (1) An individual who meets the eligibility requirements of OAR 410-142-0040 may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, his or her representative may file the election …

410-142-0110 Concurrent Care for Children (1) Under Section 2302 of the Affordable Care Act, Medicaid or Children’s Health Insurance Program (CHIP) eligible children are eligible to receive curative treatment upon the election of the hospice benefit. (2) The criteria for receivin…

410-142-0120 Duration of Hospice Care (1) An eligible individual may elect to receive hospice care during one or more of the following election periods: (a) An initial 90-day period; (b) A subsequent 90-day period; (c) An unlimited number of subsequent 60-day periods. (2) An elec…

410-142-0140 Changing the Designated Hospice (1) An individual or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received. (2) The change of the designated hospice is not a revocation of the elect…

410-142-0160 Revoking the Election of Hospice Care (1) An individual or representative may revoke the individual's election of hospice care at any time during an election period. (2) Revocation Procedure: To revoke the election of hospice care, the individual or representative mu…

410-142-0180 Plan of Care A written plan of care must be established and maintained for each individual admitted to a hospice program, and the care provided to an individual must be in accordance with the plan: (1) Establishment of Plan. The plan is established by the attending p…

410-142-0200 Interdisciplinary Group The hospice must designate an interdisciplinary group or groups composed of individuals who provide or supervise the care and services offered by the hospice: (1) Composition of group. The hospice must have an interdisciplinary group or groups…

410-142-0220 Requirements for Coverage To be covered, hospice services must meet the following requirements: (1) They must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions. (2) The individual must elect hospice car…

410-142-0225 Signature Requirements (1) The Division of Medical Assistance Programs (Division) requires practitioners to sign for services they order. This signature shall be handwritten or electronic, (or facsimiles of original written or electronic signatures for terminal illne…

410-142-0240 Hospice Core Services The following services are covered hospice services when consistent with the plan of care and must be provided in accordance with recognized standards of practice: (1) Nursing services. The hospice must provide nursing care and services by or un…

410-142-0260 Hospice Level of Care (1) Each day of hospice care is classified into one of five levels of care. The level of care determines the payment for each day of hospice benefit: (a) Routine Home Care. A routine home care day is a day on which a patient who has elected to r…

410-142-0280 Recipient Benefits An individual who has elected to receive hospice care remains entitled to receive other services not included in the hospice benefit. These services are subject to the same rules as for non-hospice clients. Typical services used that are not covere…

410-142-0290 Hospice Services in a Nursing Facility (1) Pursuant to Title XIX, Section 1902 and 1905, federal statute prohibits the state from paying nursing facility (NF) providers directly for NF services when their Medicaid residents elect hospice care. In these instances, the…

410-142-0300 Hospice Reimbursement and Limitations (1) The Division recalculates its hospice rates annually. When billing for hospice services, the provider must bill the usual charge or the rate based upon the geographic location in which the care is furnished, whichever is lowe…

410-142-0380 Death With Dignity (1) Death with dignity services are defined in the Division of Medical Assistance Programs (Division) Medical-Surgical Services and Pharmaceutical Services program rules. (2) All death with dignity services must be billed directly to Division, even…

410-144-0000 Purpose These rules outline the requirements for participation in three different Workforce Development programs for supplemental payment through Medicaid which were enacted by the Oregon legislature under Senate Bill 800 (Enrolled 2021 Regular Session), House Bill 3…

410-144-0005 Definitions (1) “Employee Retirement Income Security Act of 1974 (ERISA)” means the federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. (2) “Ess…

410-144-0010 Eligibility (1) Requirements for an employer to be eligible to participate in the Essential Workforce Health Care Program include that the employer shall: (a) Have a signed memorandum of understanding with the Oregon Health Authority (Authority) that specifies how th…

410-144-0020 Memorandum of Understanding All participating employers that receive a supplemental payment under these programs shall sign a Memorandum of Understanding with the Authority. The Memorandum of Understanding shall document the requirements and responsibilities for usin…

410-144-0025 Use of Supplemental Payments Participating employers who receive supplemental payments under the EWHP, EWDP, or UWHP must use the supplemental payments as outlined in this rule and as further detailed in the MOU entered into with the Authority. (1) Payments under Ess…

410-144-0030 Evidence-based Workforce and Quality of Care Improvements Participating employers in Essential Workforce Health Care Program must participate in evidence-based workforce and quality of care improvements, including all of the requirements in this rule. (1) Workforce i…

410-144-0040 Annual Reporting of Quality Metrics (1) Essential Workforce Health Care Fund (EWHF) shall annually provide reports on the following metrics related to quality health benefits: (a) Health benefits design, including total premium, employer/employee premium split, deduc…

410-144-0050 Supplemental Payments Methodology Supplemental payments are determined using the following methods: (1) The aggregate available supplemental payment amount for privately-owned Nursing Facilities (NFs) is calculated for each aggregate Medicaid supplemental payment lim…

410-144-0060 Oversight All payments authorized for these Programs are subject to audit at the discretion of the Authority. The Authority will terminate payments if the provider fails to abide by or violates the terms of their signed MOU. A provider may request a contested case pr…

410-145-0000 Definitions As used in this division unless the context requires otherwise: (1) “Board of governors” means the governors of a cooperative program as described in OAR 410-145-0020. (2) “Cooperative program” means a program among two or more health care providers for t…

410-145-0010 Application Procedures (1) The Oregon Health Sciences University and one or more entities, each of which operates at least three hospitals in a single urban area in this state, may apply to the director for approval of a cooperative program. (2) The application must …

410-145-0020 Board of Governors (1) If the director issues an order approving an application for a cooperative program under OAR 410-145-0010, the director shall establish a board of governors to govern the cooperative program. The board of governors shall not constitute, for any…

410-145-0030 Annual Report Not later than 60 days following each anniversary date of the director’s approval of a cooperative program, the board of governors of the cooperative program shall deliver four copies of an annual report to the director, accompanied by a review fee of $…

410-145-0040 Review and Evaluation of Annual Report (1) The director shall review and evaluate the annual report delivered under OAR 410-145-0030. The director shall: (a) Determine the extent to which the cooperative program is achieving the goals identified in the order; (b) Rev…

410-145-0050 Complaint Procedure (1) Any person may file a complaint with the director requesting that a specific decision or action of a cooperative program supervised by the director be reversed or modified, or that approval for all or part of the activities permitted by the or…

410-145-0060 Action on Complaints (1) During the review of the annual report described in OAR 410-145-0040, after receiving a complaint under 410-145-0050, or on the director’s own in initiative, the director may take one or more of the following actions: (a) If the director dete…

410-145-0070 Confidentiality of Information (1) If parties to a cooperative program agreement provide the director with written or oral information that is confidential or otherwise protected from disclosure under Oregon law, the disclosures shall not be considered a waiver of an…

410-145-0080 Reconsideration and Judicial Review (1) Orders, modifications of orders, findings and directives issued under OAR 410-145-0010, 410-145-0040(3), or 410-145-0060(1)(a) are subject to reconsideration and stay under the procedures provided in 137-003-0080 through 137-00…

410-146-0000 Foreword (1) The Health Systems Division (Division) American Indian/Alaska Native (AI/AN) Oregon Administrative Rules are designed to assist the following providers to prepare claims for services provided to clients with Medical Assistance Program coverage: (a) India…

410-146-0020 Memorandum of Agreement Reimbursement Methodology (1) In 1996, a Memorandum of Agreement (MOA) between the Centers for Medicare and Medicaid Services (CMS) and the Indian Health Service (IHS) established the roles and responsibilities of CMS and IHS regarding the Div…

410-146-0021 American Indian/Alaska Native (AI/AN) Provider Enrollment (1) This rule outlines the Division requirements for Indian Health Service (IHS) and Tribal 638 clinics to enroll as American Indian/Alaska Native (AI/AN) providers (refer to OAR 410-120-1260, Provider Enrollm…

410-146-0040 ICD-10-CM Diagnosis Codes and CPT/HCPCs Procedure Codes (1) The Division requires diagnosis codes on all claims including those submitted by independent laboratories and portable radiology and including nuclear medicine and diagnostic ultrasound providers. A clinic m…

410-146-0060 Prior Authorization (1) Some covered services or items require prior authorization (PA) by the Division before the service may be provided or before payment will be made. Refer to Oregon Administrative Rule (OAR) 410-120-1320 Authorization of Payment. (2) Most Oregon…

410-146-0075 Client Copayments (1) AI/AN clients who are members of a federally recognized Indian Tribe or Tribal Organization and receive Medicaid-covered services rendered through an IHCP are exempt from copayments. Refer to OAR 410-120-1230 Client Copayment. (2) IHCPs may not …

410-146-0080 Professional Ambulatory Services (1) Professional Ambulatory services provided by IHCP include Medical, Diagnostic, Screening, Dental, Vision, Physical Therapy, Occupational Therapy, Podiatry, Behavioral Health, Substance Use Disorder, Maternity Case Management, Spee…

410-146-0085 Encounter and Recognized Practitioners Encounter and Recognized Practitioners (1) The Division shall reimburse enrolled AI/AN providers as follows: (a) For services, items, and supplies that meet the criteria of a valid encounter in sections (5) through (7) of this r…

410-146-0086 Multiple Encounters (1) An “encounter” has the meaning given that term in OAR 410-146-0085. (2) The following services may be considered as multiple encounters when two or more service encounters are provided on the same date of service with distinctly different diag…

410-146-0100 Vaccines for Children (1) The Vaccines for Children (VFC) program supplies federally purchased free vaccines for immunizing eligible clients ages 0 through 18 at no cost to participating health care providers. For more information on how to enroll in the VFC program,…

410-146-0120 Maternity Case Management Services (1) The Division shall reimburse IHCP for MCM services according to their encounter rate. (2) MCM service is optional coverage for Prepaid Health Plans (PHPs). Before providing MCM services to clients enrolled in a PHP, determine if…

410-146-0130 Modifiers (1) The Division uses HIPAA compliant modifiers for many services. (2) The following services require the use of a modifier for all services for all procedures: (a) Family planning service -- FP, refer to OAR 410-130-0585 Family Planning Services; (b) Vacci…