Or. Admin. Code § 410-121-3000

Current through Register Vol. 63, No. 10, October 1, 2024

Section 410-121-3000 - Runumbered

(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 [File Link Not Available].

(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.

Or. Admin. Code § 410-121-3000

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

Stat. Auth.: ORS 431.830

Stats. Implemented: ORS 431.830