Oregon Administrative Rules Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS
Oregon Administrative Rules (OAR) Chapter 410 is a comprehensive set of regulations issued by the Oregon Health Authority (OHA), specifically its Health Systems Division, concerning Medical Assistance Programs.
This chapter forms the backbone of Oregon's Medicaid program, primarily the Oregon Health Plan (OHP), and dictates how medical assistance is provided to eligible individuals in the state.
Here's a breakdown of the key areas and concepts you'll find within OAR Chapter 410:
Eligibility for Medical Programs (Division 200): These rules define who is eligible for various medical assistance programs under OHA, including income, residency, and other criteria. This also includes specific eligibility requirements based on federal regulations and Oregon's 1115 OHP waiver demonstration.
Medical Assistance Benefit Packages and Delivery System (Division 120, and others): This is a critical section, detailing the specific health services and benefits covered under different OHP benefit packages (e.g., OHP Plus, OHP with Limited Drugs, Qualified Medicare Beneficiary-Only, Citizen/Alien-Waived Emergency Medical). It outlines coverage, limitations, and exclusions for a vast array of services.
Provider Rules and Requirements: The chapter establishes rules for healthcare providers who participate in Medical Assistance Programs. This includes:
Provider Enrollment: How providers become authorized to bill OHP.
Billing and Payment: Regulations for submitting claims, payment methodologies, and recoupment of overpayments.
Compliance and Sanctions: Rules regarding compliance with federal and state statutes, program integrity, audits, and potential sanctions for non-compliance or fraud.
Specific Service Categories: Many divisions within Chapter 410 are dedicated to detailed rules for particular types of medical services, such as:
Pharmaceutical Services (Division 121)
Durable Medical Equipment, Prosthetic Orthotics and Supplies (DMEPOS) (Division 122)
Dental/Denturist Services (Division 123)
Hospital Services (Division 125)
Home Health Care Services (Division 127)
Speech-Language Pathology, Audiology, and Hearing Aid Services (Division 129)
Medical-Surgical Services (Division 130)
Physical and Occupational Therapy Services (Division 131)
Medical Transportation Services (Division 136)
Visual Services (Division 140)
Hospice Services (Division 142)
And many more, covering a comprehensive range of healthcare needs.
Coordinated Care Organizations (CCOs) (Division 141 and others): A significant aspect of Oregon's health system is the use of CCOs, which are entities responsible for integrated and coordinated healthcare delivery for OHP members. Chapter 410 details the roles, responsibilities, and requirements for CCOs, including care coordination, network adequacy, and compliance.
Client Rights and Responsibilities: Rules outlining the rights of OHP clients, as well as their responsibilities. This includes procedures for contested case hearings related to service denials, reductions, or terminations.
Telehealth (Division 120, specifically OAR 410-120-1990): This section addresses the use of telemedicine in the delivery of health services, including requirements for its application and reimbursement.
In essence, OAR Chapter 410 provides the legal and regulatory framework for how the Oregon Health Authority, through its Health Systems Division, administers and oversees the Oregon Health Plan and other medical assistance programs, ensuring access to healthcare for eligible residents and regulating the providers who deliver those services.
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