Oregon Administrative Code

410-165-0120 Appeals (1) The appeals process for the Program is governed by 42 CFR 495.370 and the Authority’s Provider Appeals Rules in chapter 410, division 120. (2) Pursuant to 42 CFR 495.312 and 42 CFR 495.370, the Authority may have CMS conduct the audits and handle any subs…

410-165-0140 Oversight and Audits (1) A provider who qualifies for a Medicaid Electronic Health Record (EHR) incentive payment under the Program is subject to audit or other post-payment review procedures pursuant to OAR 943-120-1505. (2) The Authority and the Department of Human…

410-170-0000 Administration of the Behavior Rehabilitation Services (BRS) Program (1) All BRS contractors shall, and ensure that their BRS providers, comply with the Medical Assistance programs rules in OAR Chapter 410, Division 120. (2) All BRS contractors shall, and ensure that…

410-170-0010 Purpose The purpose of the Behavior Rehabilitation Services (BRS) Program is to remediate the BRS client’s debilitating psychosocial, emotional, and behavioral disorders by providing such services as behavioral intervention, counseling, and skills-training. Services …

410-170-0020 Definitions The following definitions apply to terms used in OAR Chapter 410, Division 170. (1) “Accreditation” as defined in OAR 413-095-0000(2) means: (a) An endorsement certifying that the BRS program meets all of the rigorous guidelines for service and quality es…

410-170-0030 BRS Contractor and BRS Provider Requirements (1) The BRS contractor shall ensure that its BRS providers meet the following minimum requirements: (a) Have the necessary current and valid licenses, approvals, or certifications required by federal or state law or regula…

410-170-0040 Prior Authorization for the BRS Program; Hearing Rights (1) The BRS program requires prior authorization from the agency in accordance with the Authority’s rules, the general BRS program rules, and applicable agency-specific BRS program rules. A referral by an LPHA o…

410-170-0050 Program Referrals and Admission to BRS Provider (1) After the BRS client receives prior authorization for the BRS program, the agency shall refer the BRS client for admission to one or more BRS contractors or BRS providers that provide the appropriate BRS type of car…

410-170-0060 Discharge from the BRS Contractor or BRS Provider (1) Planned discharge initiated by the BRS contractor, BRS provider, or the agency: (a) Initiated by the BRS contractor or BRS provider: (A) The BRS contractor shall, and require that its BRS providers, notify the cas…

410-170-0070 BRS Service Planning (1) Initial Service Plan (ISP): (a) A BRS contractor that provides services and placement-related activities in a Shelter, Independent Living program, Enhanced Structure Independent Living program, Proctor Care, Proctor Enhanced Services, Assessm…

410-170-0080 Services (1) The BRS contractor shall, and require that its BRS provider, provide services to the BRS client in accordance with the BRS client’s service plan. (2) BRS contractor staff shall, and require that its BRS provider, staff structure and directly supervise al…

410-170-0090 BRS Types of Care (1) Shelter, Community Step-Down, and Independent Living Program: (a) The BRS contractor or BRS provider may use either a residential care model or proctor care model for these BRS types of care; (b) The BRS contractor providing one of these BRS typ…

410-170-0100 Placement-Related Activities for the Authority’s BRS Contractors and BRS Providers (1) In cases where the Authority is the agency, the BRS contractor shall, and require that its BRS provider, provide the following placement-related activities and all facilities, pers…

410-170-0110 Billing and Payment for Services and Placement-Related Activities Effective July 1, 2025: (1) The BRS contractor is compensated for a billable care day (service and placement-related activities rates) on a fee-for-service basis, except as otherwise provided for in th…

410-170-0120 Compliance Reviews and Sanctions (1) The BRS contractor shall cooperate and ensure its BRS providers cooperate with program compliance reviews or audits conducted by any federal or state or local governmental agency or entity related to the BRS program. (2) The Autho…

410-172-0600 Acronyms and Definitions (1) “Activity of Daily Living (ADLs)” means those personal and functional activities required by an individual for continued well-being, that are essential for health and safety. ADLs include eating, bathing, dressing, toileting, transferring…

410-172-0610 Provider Enrollment (1) Providers shall be enrolled with the Division as a behavioral health provider. Paid providers of behavioral health services shall possess a current and valid license, letter, or certificate. (2) Providers shall provide services within the scop…

410-172-0620 Documentation Standards (1) OHP providers shall maintain records that fully support the extent of services for which payment has been requested and provide the records to the Division upon request. (2) All records shall document the specific service provided, the num…

410-172-0630 Medically Appropriate (1) In addition to the definition of medically appropriate in OAR 410-120-0000 for behavioral health services, “medically appropriate” means the services and supports required to diagnose, stabilize, care for, and treat a behavioral health condi…

410-172-0640 Behavioral Health Services Fee Schedule (1) The Division shall pay providers based on the Behavioral Health Services Fee Schedule (fee-for-service (FFS) payment rates for behavioral health services) posted on the Authority web site. (2) Payment shall be made at each …

410-172-0650 Prior Authorization (1) Some services or items covered by the Division require authorization before the service may be provided. Services requiring prior authorization are published on the Medicaid Behavioral Health Services Fee Schedule. (2) The Division shall autho…

410-172-0660 Rehabilitative Behavioral Health Services (1) Rehabilitative behavioral health services means medical or remedial services recommended by a licensed medical practitioner or other licensed practitioner to reduce impairment to an individual’s functioning associated wit…

410-172-0670 Substance Use Disorder Treatment Services (1) Substance Use Disorder (SUD) treatment services shall be culturally and linguistically responsive and include; screening, assessment, individual counseling, group counseling, individual family and/or couple counseling, gr…

410-172-0680 Residential Treatment Services for Children (1) Paid providers of children’s psychiatric residential treatment services shall: (a) Hold a Certificate of Approval Pursuant to OAR 309-012-0130 through 309-012-0220 from AMH; and (b) Be accredited as a psychiatric reside…

410-172-0690 Admission Procedure for Psychiatric Residential Treatment Services for Children (1) Admission procedures for children eligible for Medicaid shall be reviewed through an independent psychiatric review process established by the Division to certify the need for service…

410-172-0695 Intensive In-Home Behavioral Health Treatment Services for Youth (IIHBT) (1) IIBHT services as described in OAR 309-019-0167 are intended as an outcome-based, transitional, and episodic period of care to provide service and supports in a natural environment that allo…

410-172-0705 Residential Rate Standardization (1) The following terms and acronyms have the described meanings when appearing in OAR 410-172-0705: (a) “Acuity” means the level of residential service and support needs of an individual experiencing functional deficits resulting fro…

410-172-0710 Residential Personal Care (1) Personal care services shall be provided to residents of Division licensed residential treatment programs, as developmentally appropriate, as described in the resident’s person-centered service plan and residential plans of care. (2) Per…

410-172-0720 Prior Authorization and Re-Authorization for Residential Treatment (1) The Authority does not consider a request for a fixed episode of care or standardized length of stay to be medically appropriate. Requested length of stay shall be based on an assessment of indivi…

410-172-0730 Payment Limitations for Behavioral Health Services (1) Services shall be subject to periodic utilization review to determine medical appropriateness. (2) If a review reveals that a recipient received less than active treatment, payment may not be allowed under these …

410-172-0760 Applied Behavior Analysis (1) Applied Behavior Analysis (ABA) services for the treatment of autism spectrum disorder shall be recommended by a licensed practitioner who has experience in the diagnosis and treatment of autism spectrum disorder and holds at least one o…

410-172-0770 Individual Eligibility for Applied Behavioral Analysis Treatment (1) Prior to receiving services, individuals receiving ABA services for the treatment of autism spectrum disorder (ASD) shall have an evaluation by a licensed practitioner, described in OAR 410-172-0760…

410-172-0776 Behavioral Health Personal Care Attendant (BH PCA) Program Definitions Unless the context indicates otherwise, the following definitions apply to the rules in OAR 410-172-0775 through OAR 410-172-0840 Personal Care Attendant Program: (1) "Alternative Service Resource…

410-172-0780 Behavioral Health Personal Care Attendant Program (1) The Behavioral Health Personal Care Attendant (BH PCA) program ensures state plan personal care services support and augment independence, empowerment, dignity and human potential through the provision of flexible…

410-172-0790 Eligibility for Behavioral Health Personal Care Attendant Services (1) To be eligible for personal care services through the BH PCA program, an individual shall: (a) Demonstrate the need for assistance with personal care services from a qualified provider due to a di…

410-172-0796 Applying for State Plan Personal Care Services (1) Individuals of any age who are eligible for behavioral health personal care attendant (BH PCA) services as described OAR 410-172-0790(1) may apply through the Independent Qualified Agent (IQA) contracted with the Aut…

410-172-0800 Personal Care Attendant Employer-Employee Relationship (1) To be eligible for the BH PCA program, the individual or the individual’s consumer-employer representative shall demonstrate the ability to perform the following consumer-employer responsibilities: (a) Locate…

410-172-0820 Provider Enrollment Termination (1) The Authority may take action, including denial, suspension or termination, on a personal care attendant’s provider enrollment or re-enrollment, and the provider number as described in OAR Chapter 410 Division 120. The termination,…

410-172-0830 Personal Care Attendant Service Assessment, Authorization and Monitoring (1) The Division administers the personal care services program and may use a designee also known as the Independent and Qualified Agent (IQA). The IQA is responsible for: (a) Receiving and proc…

410-172-0840 Personal Care Attendant Payment Limitations (1) The number of personal care service hours authorized through the BH PCA program for an individual per 14-day service period is based on projected amounts of time to perform specific personal care services to the eligibl…

410-172-0850 Telemedicine for Behavioral Health (1) Telemedicine encompasses different types of programs, services, and delivery mechanisms for medically appropriate covered services within the recipient’s benefit package: (a) Patient consultations using telephone and online or e…

410-172-0860 Billing for Dual Eligible Individuals (1) As described in OAR 410-120-1280 (8), when an individual has both Medicare and coverage through Medicaid, providers shall make reasonable efforts to obtain payment from other resources including Medicare or other Third Party …

410-173-0000 Purpose (1) These rules ensure eligible Individuals served by the Oregon Health Authority (Authority), Health Systems Division (Division), have access to 1915(i) Home and Community Based State Plan Option services that are not defined in other rules in this chapter. …

410-173-0005 Definitions (1) "Activities of Daily Living (ADL)," means functional activities required by an individual for continued well-being that are essential for health and safety. ADL’s include eating, dressing/grooming, bathing/personal hygiene, mobility (ambulation and tr…

410-173-0010 Eligibility (1) Individuals applying to receive state plan 1915(i) HCBS shall be determined by the Department of Human Services (Department) to meet Title XIX Medicaid eligibility criteria. The Department shall complete Title XIX Medicaid eligibility determinations a…

410-173-0015 Service Authorization (1) Authorization medical appropriateness and medical necessity for Residential Habilitation are satisfied by face-to-face eligibility or re-eligibility assessments of 1915(i) HCBS State Plan Option. These services include: (a) Completion of a D…

410-173-0020 Functional Needs Assessment (1) The IQA shall meet face-to-face with Individuals or if applicable, their legal or authorized representative and in consultation with other persons identified by the individual to complete a Functional Needs Assessment to determine: (a)…

410-173-0025 Person-Centered Service Planning Process (1) A person-centered service plan shall be developed through a person-centered service planning process that includes the following: (a) Be completed face-to-face with the Individual to ensure the individual’s involvement and…

410-173-0030 Qualifications for Home and Community Based Services Providers (1) Providers of 1915(i) HCBS shall meet the following qualifications for each type of service they are providing as described in this rule and: (a) Meet all necessary provider qualifications, including r…

410-173-0035 Home and Community Based Services and Setting Qualities (1) Residential and non-residential HCBS settings shall support Individuals in having the same opportunities for integration, access, choice, and rights as Individuals not accessing 1915(i) HCBS; (2) Providers o…