Or. Admin. Code § 410-141-3820

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-141-3820 - Covered Services

(1) General standard. The OHP Benefit Package includes treatments and health services which pair together with a condition on the same line of the Health Evidence Review Commission (HERC) Prioritized List of Health Services adopted under OAR 410-141-3830, to the extent that such line appears in the funded portion of the Prioritized List of Health Services. Coverage of these services is included in the benefit package when provided as specified in any relevant Statements of Intent and Guideline Notes of the Prioritized List of Health Services. The Benefit Package also covers the additional services described in this rule.

(a) As used in OAR 410-141-3820 and OAR 410-141-3825, the word "health services" has the meaning given in ORS 414.025(13);

(b) Services are covered with respect to an individual member only when the services are medically or orally necessary and appropriate as defined in OAR 410-120-0000 and at the time they are provided, except that services shall also meet the prudent layperson standard defined in ORS 743A.012.

(c) HRSN Services are covered with respect to an individual member only when the Member belongs to an HRSN Covered Population and meets other service-specific eligibility criteria as defined in OAR 410-120-0000, OAR 410-120-2000, and OAR 410-120-2005.

(d) Benefit Package coverage of prescription drugs is discussed in OAR 410-141-3855;

(e) The Benefit Package is subject to the exclusions and limitations described in OAR 410-141-3825.

(2) MCE service offerings:

(a) MCEs shall offer their members, at a minimum:

(A) The physical, behavioral and/or oral health services covered under the member's benefit package, as appropriate for the MCE's mandatory scope of services; and

(B) Any additional services required in OAR chapter 410, or in the MCE contract.

(b) CCOs shall coordinate physical health, behavioral health, oral health care benefits, and HRSN benefits;

(c) With respect to members who are dually eligible for Medicare and Medicaid, MCEs shall provide:

(A) OHP Benefit Package services except for Medicaid-funded long-term care, services, and supports; and

(B) Secondary payment for services covered by Medicare but not otherwise covered under the Oregon Health Plan as specified in OAR 410-141-3565 and specific to benefit packages in OAR 410-120-1210.

(3) Diagnostic services. Diagnostic services that are medically or orally appropriate and medically or orally necessary to diagnose the member's presenting condition (signs and symptoms) or guide management of a member's condition, regardless of whether the condition appears above or below the funded line on the Prioritized List of Health Services. Coverage of diagnostic services is subject to any applicable Diagnostic Guidelines on the Prioritized List of Health Services.

(4) Comfort care. Comfort care is a covered service for a member with a terminal illness.

(5) Preventive services. Preventive Services are included in the OHP benefit package as described in the funded portion of the Prioritized List of Health Services, as specified in related guideline notes. These services include, but are not limited to, periodic medical and dental exams based on age, sex, and other risk factors; screening tests; immunizations; and counseling regarding behavioral risk factors.

(6) Ancillary services. Ancillary services are covered subject to the service limitations of the Oregon Health Plan (OHP) program rules when:

(a) The services are medically or orally necessary and appropriate in order to provide a funded service; or

(b) The provision of ancillary services shall enable the member to retain or attain the capability for independence or self-care;

(c) Coverage of ancillary services is subject to any applicable Ancillary Guidelines on the Prioritized List of Health Services.

(7) SUD services. The provision of SUD services shall comply with OAR 410-141-3545.

(8) Services necessary for compliance with the requirements for parity in mental health and substance use disorder benefits in 42 CFR part 438, subpart k.

(9) Services necessary for compliance with the requirements for Early and Periodic Screening, Diagnosis and Treatment as specified in the Oregon Health Plan 1115 Demonstration Project (waiver) and meeting requirements for individualized determination of medical necessity as specified in OAR 410-130-0245.

(10) Services necessary for compliance with the requirements for HRSN Services (as described in Oregon's Medicaid 1115 Waiver for 2022-2027) and meeting requirements for individualized determination of Service authorization as specified in OAR 410-141-3835.

(11) Coverage of services for unfunded conditions based on effect on funded comorbid conditions:

(a) The OHP Benefit Package includes coverage in addition to that available under subsection (1). Specifically, it includes coverage of certain medically necessary and appropriate services for conditions which appear below the funding line in the Prioritized List of Health Services if it can be shown that:

(A) The member has a funded condition for which documented clinical evidence shows that the funded treatments are not working or are contraindicated; and

(B) The member concurrently has a medically related unfunded condition that is causing or exacerbating the funded condition; and

(C) Treating the unfunded medically related condition may significantly improve the outcome of treating the funded condition.

(b) Services that are expressly excluded from coverage as described in OAR 410-141-3825 are not subject to consideration for coverage under subsection (11);

(c) Any co-morbid conditions or disability shall be represented by an ICD diagnosis code or, when the condition is a mental disorder, represented by a DSM diagnosis;

(d) In order for the services to be covered, there shall be a medical determination and finding by the Authority (for fee-for-service OHP clients) or by the MCE (for MCE members) that the terms of subsection (a) of this rule have been met based upon the applicable:

(A) Treating health care provider opinion;

(B) Medical research; and

(C) Current peer review.

(12) Ensuring that all coverage options are considered:

(a) When a provider receives a denial for a non-covered service for any member, especially a member with a disability or with a co-morbid condition, the provider shall determine whether there may be a medically appropriate covered service to address the member's condition or clinical situation, before declining to provide the non-covered service. The provider's determination shall include consideration of whether a service for an unfunded condition may improve a funded comorbid condition under section (11);

(b) If a member seeks, or is recommended, a non-covered service, providers shall ensure that the member is informed of:

(A) Clinically appropriate treatment that may exist, whether covered or not;

(B) Community resources that may be willing to provide the relevant non-covered service;

(C) If appropriate, future health indicators that may warrant a repeat evaluation visit.

(c) Before an MCE denies coverage for an unfunded service for any member, especially a member with a disability or with a co-morbid condition, the MCE shall determine whether the member has a funded condition or condition/treatment pair that may entitle the member to coverage under the program.

(13) Assistance to providers. The Authority shall maintain a telephone information line for the purpose of assisting practitioners in determining coverage under the OHP Benefit Package. The telephone information line shall be staffed by registered nurses who shall be available during regular business hours. If an emergency need arises outside of regular business hours, the Authority shall make a retrospective determination under this section, provided the Authority is notified of the emergency situation during the next business day. If the Authority denies a requested service, the Authority shall provide written notification and a notice of the right to an administrative hearing to both the OHP member and the treating physician within five (5) working days of making the decision.

(14) Ad hoc coverage determinations.

(a) When a member requests a hearing pertaining to a funded condition and a funded or unfunded treatment that does not pair on the HERC Prioritized List of Health Services, and the treatment is not included in guideline note 172 or 173 of the prioritized list, before the hearing the Division shall determine if the requested treatment is appropriate and necessary for the member.

(b) For treatments determined to be appropriate and necessary under subsection (a), the Division determines whether the HERC has considered the funded condition/treatment pair for inclusion on the Prioritized List within the last five (5) years. If the HERC has not considered the pair for inclusion within the last five (5) years, the Division shall make an ad hoc coverage determination in consultation with the HERC.

(c) For treatments determined to not be appropriate and necessary under (a) in this section the hearing process shall proceed.

(15) General anesthesia for oral procedures. General anesthesia for oral procedures that are medically and orally necessary and appropriate to be performed in a hospital or ambulatory surgical setting may be used only for those members as detailed in OAR 410-123-1490.

Or. Admin. Code § 410-141-3820

DMAP 56-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021; DMAP 35-2024, amend filed 01/22/2024, effective 1/22/2024; DMAP 80-2024, minor correction filed 03/22/2024, effective 3/22/2024; DMAP 130-2024, amend filed 10/24/2024, effective 11/1/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.065, 414.572, 414.605, 414.665 & 414.719