Or. Admin. Code § 333-022-1145

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-022-1145 - Uninsured Persons Program

(1) The Uninsured Persons Program (UPP) provides full-cost coverage for a limited number of medications and medical services for clients who are ineligible for insurance.

(2) In order to be eligible for UPP an individual must:

(a) Meet all eligibility requirements outlined in OAR 333-022-1020; and

(b) Be ineligible for public and private insurance that meets minimum essential coverage under the federal Affordable Care Act, Public Law 111-148; and

(c) Be enrolled in Ryan White community-based HIV Case Management Services.

(3) To apply for UPP an individual must comply with OAR 333-022-1030 and an application shall be reviewed by the Authority in accordance with OAR 333-022-1040, as applicable.

(4) If the Authority determines that an applicant is eligible for CAREAssist benefits the applicant shall be notified in writing within 10 business days of the Authority's determination. A client's notification must describe:

(a) The eligibility effective date and end date;

(b) Group number and benefits associated with that group;

(c) A list of CAREAssist in-network pharmacies;

(d) Recertification date and process; and

(e) The repercussions of not recertifying.

(5) UPP eligibility is for six months.

(6) If the Authority determines that an applicant is not eligible for UPP benefits an applicant will be notified in writing in accordance with ORS 183.415.

(7) An applicant who is denied may reapply at any time.

(8) UPP benefits include:

(a) Assistance with the cost of prescription drugs listed on the CAREAssist formulary, when dispensed by a CAREAssist contract in-network pharmacy;

(b) Full-cost laboratory and medical visits performed in an out-patient setting. Coverage is limited to allowable CPT codes, as designated by the program. The program may cover the cost of each allowable CPT code up to four times a year. Any additional coverage requires prior authorization initiated by the client's prescribing physician.

(c) Medication therapy management; and

(d) Tobacco cessation services.

(9) An UPP client must notify the Authority immediately if he or she becomes eligible for insurance or obtains insurance.

Or. Admin. Code § 333-022-1145

PH 30-2014, f. 11-10-14, cert. ef. 12-1-14; PH 23-2016, f. & cert. ef. 8/2/2016

Stat. Auth.: ORS 413.042, 431.250, 431.830

Stats. Implemented: ORS 431.250, 431.830