Or. Admin. Code § 410-120-1230

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

Section 410-120-1230 - Client Co-payment

(1) Effective January 1, 2017, Oregon Health Plan (OHP) Plus clients are not responsible for paying an OHP Plus copayment.

(2) For dates of service prior to January 1, 2017, OHP Plus clients are responsible for paying a co-payment for some services. This co-payment shall be paid directly to the provider. A co-payment applies regardless of location of services rendered, i.e., provider's office or client's residence.

(3) The following services are exempt from co-payment:

(a) Emergency medical services as defined in OAR 410-120-0000;

(b) Family planning services and supplies;

(c) Prescription drug products for nicotine replacement therapy (NRT);

(d) Prescription drugs ordered through the Division's Mail Order (a.k.a., Home-Delivery) Pharmacy program;

(e) Services to treat "health care-acquired conditions" (HCAC) and "other provider preventable conditions" (OPPC) services as defined in OAR 410-125-0450.

(4) The following clients are exempt from co-payments:

(a) Pregnant women;

(b) Children under age 19;

(c) Young adults in substitute care and in the former Foster Care Youth Medical program;

(d) Clients receiving services under the Medicaid-funded home and community-based services program;

(e) Inpatients in a hospital, nursing facility, or Intermediate Care Facility for Intellectually or Developmentally Disabled Page 1 of 2 (ICF/IDD);

(f) American Indian/Alaska Native (AI/AN) clients who are members of a federally recognized Indian tribe or receive services through Indian Health Services (IHS), a tribal organization, or services provided at an Urban Tribal Health Clinic as provided under Public Law 93-638;

(g) Individuals receiving hospice care;

(h) Individuals eligible for the Breast and Cervical Cancer program.

(5) For services provided prior to January 1, 2017:

(a) Co-payment for services is due and payable at the time the service is provided unless exempted in sections (2) and (3) above. Services to a client may not be denied solely because of an inability to pay an applicable co-payment. This does not relieve the client of the responsibility to pay the applicable co-payment, nor does it prevent the provider from attempting to collect any applicable co-payments from the client. The co-payment is a legal debt and is due and payable to the provider of service;

(b) Except for prescription drugs, one co-payment is assessed per provider/per visit/per day unless otherwise specified in other Division's program administrative rules;

(c) Fee-for-service co-payment requirements:

(A) The provider may not deduct the co-payment amount from the usual and customary billed amount submitted on the claim. Except as provided in section (3) and (4) of this rule, the Division shall deduct the co-payment from the amount the Division pays to the provider (whether or not the provider collects the co-payment from the client);

(B) If the Division's payment is less than the required co-payment, then the co-payment amount is equal to the Division's lesser required payment, unless the client or services are exempt according to exclusions listed in section (3) and (4) above. The client's co-payment shall constitute payment-in-full;

(C) Unless specified otherwise in individual program rules and to the extent permitted under 42 CFR 1001.951-1001.952, the Division does not require providers to bill or collect a co-payment from the Medicaid client. The provider may choose not to bill or collect a co-payment from a Medicaid client; however, the Division shall still deduct the co-payment amount from the Medicaid reimbursement made to the provider.

(d) CCO or PHP co-payment requirements:

(A) Unless specified otherwise in individual program rules and to the extent permitted under 42 CFR 447.58 and 447.60, the Division does not require CCOs or PHPs to bill or collect a co-payment from the Medicaid client. The CCO or PHP may choose not to bill or collect a co-payment from a Medicaid client; however, the Division shall still deduct the co-payment amount from the Medicaid reimbursement made to the CCO or PHP;

(B) When a CCO or PHP is operating within the scope of the safe harbor regulation outlined in 42 CFR 1001.952(l), a CCO or PHP may elect to assess a co-payment on some of the services outlined in Table 120-1230-1 but not all. The CCO or PHP must assure they are working within the provisions of 42 CFR 1003.102(b)(13) . [Table not included. See ED. NOTE.]

(6) Services that require co-payments are listed in Table 120-1230-1. [Table not included. See ED. NOTE.]

(7) Table 120-1230-1. [Table not included. See ED. NOTE.]

Or. Admin. Code § 410-120-1230

OMAP 73-2002, f. 12-24-02, cert. ef. 1-1-03; OMAP 73-2003, f. & cert. ef. 10-1-03; OMAP 39-2004(Temp), f. 6-14-04 cert. ef. 6-19-04 thru 11-30-04; OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 5-2008, f. 2-28-08, cert. ef. 3-1-08; DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14; DMAP 23-2014, f. & cert. ef. 4-4-14; DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14; DMAP 52-2016, f. 8-26-16, cert. ef. 9/1/2016; DMAP 78-2016, f. 12-29-16, cert. ef. 1/1/2017; DMAP 28-2019, repeal filed 08/02/2019, effective 8/2/2019

Tables referenced are available from the agency.

Statutory/Other Authority: ORS 413.042ORS413.042

Statutes/Other Implemented: ORS 414.025, 414.065