Oregon Administrative Code

333-004-3080 Reproductive Health Access Fund Excluded Services by Funding Source (1) Title X does not cover: (a) Sterilizations for enrollees assigned female at birth; (b) Treatment for sexually transmitted infections (STIs) not pursuant to a family planning visit; (c) Stand-alon…

333-004-3090 Client Eligibility for the RH Access Fund (1) To be considered eligible for the RH Access Fund, an enrollee must meet the eligibility requirements for Title X, CCare, or RHEA. (a) Title X. To qualify for Title X, an enrollee must: (A) Have a household size and person…

333-004-3100 Client Enrollment into the Reproductive Health Access Fund (1) To enroll in the Reproductive Health Access Fund (RH Access Fund) a client must submit the following items to the clinic: (a) A signed, completed, and dated RH Access Fund Enrollment Form that includes al…

333-004-3110 Reproductive Health Access Fund Billing and Claims (1) Only agencies providing services pursuant to an approved Medical Services Agreement (MSA), and who have been assigned a project number and site number may submit claims for reproductive health or abortion service…

333-004-3120 Timely Submission of RH Access Fund Claims (1) RH Access Fund claims are processed once a month. To be included in a given month’s processing, an agency must submit a claim to the RH Program via the RH Program’s contracted data and claims processing vendor and the RH…

333-004-3130 Payment for RH Access Fund Claims (1) The RH Program shall make payments to an agency that actually performs the services for enrollees. The exception to this is if an agency contracts with a provider for RH Program-approved services, then the RH Program will make pa…

333-004-3140 Use of Funds (1) Final determination of funding source is made by the RH Program based on information recorded in the RH Access Fund eligibility database and claims data submitted by the agency. (2) Use of Title X Funds. Title X funds may only be used for the reimbur…

333-004-3150 RH Access Fund Requirements for Financial, Health, and Other Records (1) The RH Program is responsible for analyzing and monitoring the operation of the RH Access Fund, and for auditing and verifying the accuracy and appropriateness of payment and utilization of serv…

333-004-3160 Reproductive Health Access Fund Reviews and Audits (1) A Reproductive Health Program (RH Program) staff person, contractor, or auditor may review enrollment form documents to determine compliance with client eligibility and enrollment requirements. (2) A RH Program s…

333-004-3170 RH Access Fund Claim Re-determination (1) If an agency disagrees with an initial claim determination, it may request a review for re-determination of the denied claim payment. The request to open an initial claim determination for a re-determination review must be ma…

333-004-3180 Recovery of RH Access Fund Overpayments to Agencies Resulting from Review or Audit (1) When the RH Program determines that an overpayment has been made to an agency, the amount of overpayment is subject to recovery. (a) If the RH Program determines by the random samp…

333-004-3190 Compliance with Federal and State Statutes (1) Agencies are required to comply with the applicable sections of the federal and state statutes referenced in this rule. (a) 5 CFR Part 84 that implements Title V, section 504 of the Rehabilitation Act of 1973, as amended…

333-004-3200 Grounds for Agency Sanctions; Sanctions (1) The following may result in the imposition of a sanction against an agency: (a) Interference with the investigation of health care fraud; (b) Conviction for unlawfully manufacturing, distributing, prescribing, or dispensing…

333-004-3210 Agency Requests for Reconsideration (1) An agency may request reconsideration of a RH Program decision that directly adversely affects the agency such as: (a) A denial or limitation of payment allowed for services or items provided. (b) A RH Program overpayment deter…

333-004-3220 Agency Requests for Contested Case Hearings (1) An applicant agency or an agency may request a contested case hearing: (a) If a new or renewal application for certification is denied. (b) If the RH program proposes to terminate an agency’s certification. (2) An appli…

333-004-3230 Discretionary Use of Funds The RH Program may, at its discretion, use RH GF or Title X instead of CCare to reimburse an agency for CCare-covered services, referenced in OAR 333-004-3070(3)(a) (RH Access Fund Covered Services by Funding Source), provided to clients wh…

333-004-4000 Description of Abortion Access Plan The purpose of OAR 333-004-4000 through 333-004-4130 is to establish requirements for the Abortion Access Plan under which authorized providers and agencies may receive reimbursement from the Oregon Health Authority for abortion se…

333-004-4010 Definitions As used in OAR 333-004-4000 through 333-004-4130, the following definitions apply: (1) “Abortion Access Plan” means the program, administered by the Reproductive Health Program (RH Program), under which authorized providers and agencies may bill and recei…

333-004-4020 Covered Services The Abortion Access Plan covers abortion services. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 102-2024, minor correction filed 11/26/2024, effective 11/26/2024 PH 47-2023, ad…

333-004-4030 Excluded Services Services not listed as covered services in OAR 333-004-4020 are not covered by the Abortion Access Plan. Statutory/Other Authority: ORS 413.042 & ORS 435.230 Statutes/Other Implemented: ORS 413.032 & ORS 435.230 History: PH 103-2024, minor correctio…

333-004-4040 Client Eligibility To be eligible to have abortion services covered by the Abortion Access Plan, an individual must: (1) Be an eligible client; and (2) Have received services from an authorized agency or authorized provider that submits a claim for reimbursement usin…

333-004-4050 Eligibility for Reimbursement (1) To be considered an authorized agency or authorized provider and certified to receive reimbursement for abortion services covered by the Abortion Access Plan for clients an entity or provider must: (a) Be enrolled with the Oregon Hea…

333-004-4060 Abortion Access Plan Billing and Claims (1) An authorized agency or authorized provider shall complete all required fields on the Abortion Access Plan claims form prior to submission to the RH Program. (2) An authorized agency or authorized provider must not seek pay…

333-004-4070 Timely Submission of Claims (1) Claims are processed once a month. To be included in a given month’s processing, an authorized agency or authorized provider must submit a claim to the RH Program using the Abortion Access Plan claims form by electronic mail before the…

333-004-4080 Payment for Abortion Access Plan Claims (1) The RH Program shall make payments to an authorized agency or authorized provider that actually performs the services for clients. (2) Reimbursement rates for abortion services are set by the RH Program. Claims are reimburs…

333-004-4090 Review or Audit of Abortion Access Plan Claims (1) A RH Program staff person, contractor, or auditor may review a claim for assurance that: (a) Specific medical services, drugs, devices, or supplies were provided to clients by an authorized agency or authorized provi…

333-004-4100 Claim Re-Determination (1) If an authorized agency or authorized provider disagrees with an initial claim determination, it may request a review for re-determination of the denied claim payment. The request to open an initial claim determination for a re-determinatio…

333-004-4110 Recovery of Abortion Access Plan Overpayments Resulting from Review or Audit (1) When the RH Program determines that an overpayment has been made to an authorized agency or authorized provider, the amount of overpayment is subject to recovery. (a) If the RH Program d…

333-004-4120 Grounds for Sanctions; Sanctions (1) The following may result in the imposition of a sanction against an authorized agency or authorized provider: (a) Interference with the investigation of health care fraud; (b) Conviction for unlawfully manufacturing, distributing,…

333-004-4130 Requests for Reconsideration (1) An authorized agency or authorized provider may request reconsideration of a RH Program decision that directly adversely affects the agency or provider such as: (a) A denial or limitation of payment allowed for services or items provi…

333-006-0000 Purpose (1) The purpose of these rules is to establish requirements for a voluntary statewide program for providing newborn nurse home visiting services to all families with newborns residing in the state to support healthy child development and strengthen families. …

333-006-0010 Definitions (1) "Authority" means the Oregon Health Authority. (2) "Carrier" has the meaning given to that term under ORS 743B.005. (3) "Community" means a geographic region, county, Tribe or other group of individuals living in proximity. (4) "Community lead" means …

333-006-0020 Community Lead Designation (1) The Oregon Health Authority (Authority) shall designate one community lead per community. (a) Communities based on geographic areas, including counties, shall have one community lead; (b) Communities may be based on Tribal membership an…

333-006-0030 Community Lead Application Review (1) If a community lead applicant satisfies these rules, the Authority may designate the applicant as the community lead. The Authority shall notify the applicant in writing of the designation. (2) The Authority may deny designation …

333-006-0040 Community Lead Renewal and Review (1) A community lead may apply to renew its designation by submitting a complete renewal application to the Authority in the format provided by the Authority at least 60 days prior to the expiration of its current designation. (2) Th…

333-006-0050 Community Lead Services Requirements (1) Community leads must: (a) Implement a universally offered newborn nurse home visiting services model that has been reviewed by the Administration for Children and Families to meet the U.S. Health and Human Services (HHS) crite…

333-006-0060 Community Lead Training Requirements (1) Community leads must ensure staff members working with the newborn nurse home visiting program receive an orientation within six weeks of beginning work in the program that includes, but is not limited to: (a) Overview of the …

333-006-0070 Newborn Nurse Home Visiting Provider Certification (1) To apply for certification as a newborn nurse home visiting provider, an applicant must: (a) Submit a complete application, in a format prescribed by the Oregon Health Authority (Authority); (b) Submit documentat…

333-006-0080 Newborn Nurse Home Visiting Provider Application Review (1) The Authority shall review the application to determine if it is complete. If the applicant does not provide all of the documentation and information required in OAR 333-006-0070, the Authority shall reject …

333-006-0090 Newborn Nurse Home Visiting Provider Certification Renewal (1) A certified provider may apply to renew its certification by submitting a complete renewal application to the Authority in the format provided by the Authority. (2) A renewal application shall include the…

333-006-0100 Newborn Nurse Home Visiting Provider Coordination (1) Certified providers must coordinate with the community lead(s) designated in the communities that the certified provider serves, or the Oregon Health Authority (Authority) if no community lead has been designated.…

333-006-0110 Newborn Nurse Home Visiting Provider Requirements (1) Certified providers must: (a) Provide home visiting services that meet the requirements for the universally offered newborn nurse home visiting model implemented by the community lead in the provider’s identified …

333-006-0120 Newborn Nurse Home Visiting Service Requirements (1) Certified providers must timely offer the home visiting services described in this rule to families with newborns. (2) Certified providers must timely provide the home visiting services as described in this rule un…

333-006-0130 Newborn Nurse Home Visitor Provider Training Requirements (1) Certified providers shall ensure that staff working in the program timely receive the training in this rule. (2) All staff working in the program must receive training that includes an overview of the univ…

333-006-0140 Newborn Nurse Home Visiting Provider Review (1) The Oregon Health Authority (Authority), or its designee, may conduct a review of each certified newborn nurse home visiting provider within one year of initial certification to determine compliance with these rules. Th…

333-006-0150 Newborn Nurse Home Visiting Provider Compliance (1) A certified provider must notify the community lead(s) and the Oregon Health Authority (Authority) within 20 calendar days of any change that brings the provider out of compliance with these rules. (2) The Authority…

333-006-0160 Health Benefit Plans Reporting Requirements For each calendar year, carriers shall report the following de-identified information to the Authority on an annual basis: (1) Number of enrollees who added a newborn to coverage under the carrier’s health benefit plans; (2…

333-006-0180 Health Benefit Plan Reimbursement Requirements (1) As used in OAR 333-006-0180 through 333-006-0190 the following definitions apply: (a) "Billing guidance" means a document describing the claim submission process. (b) "Budget standards" means a document describing st…

333-006-0190 Reimbursement Methodology The health benefit plan reimbursement methodology for newborn nurse home visiting services is a claim invoicing process. (1) If a health benefit plan requires credentialing as a prerequisite to claim submission, health benefit plans must cre…

333-007-0300 Cannabis Testing: Purpose (1) The purpose of these rules is to establish the minimum compliance testing standards for marijuana items and industrial hemp-derived vapor items. These rules are applicable to persons who process, sell, or transfer marijuana items or indu…