OAR 410-120-1195
SB 5548 Population

Effective for services rendered on or after January 1, 2004.

(1)

Certain individuals previously participating in the OSIP-MN Medically Needy Program as of January 31, 2003, and who are identified by the Authority with specific health-related conditions as outlined in the Joint Ways and Means budget note accompanying Senate Bill 5548 (2003) shall be referred to as SB 5548 clients.

(2)

SB 5548 clients are eligible for a State-funded, limited, prescription drug benefit for covered drugs described in subsection (3) of this rule.

(3)

Eligibility for and access to covered drugs for SB 5548 clients:

(a)

SB 5548 clients must have been participating in the former OSIP-MN Medically Needy Program as of January 31, 2003, and as of that date had a medical diagnosis of HIV or organ transplant status;

(b)

SB 5548 clients receiving anti-retroviral and other prescriptions necessary for the direct support of HIV symptoms:

(A)

Must agree to participate in the Authority’s CareAssist Program in order to obtain access to this limited prescription drug benefit; and

(B)

Prescriptions are limited to those listed on the CareAssist Formulary which can be found at http://www.ramsellcorp.com/individuals/or.aspx;

(c)

SB 5548 clients receiving prescriptions necessary for the direct support of organ transplants are limited:

(A)

Drug coverage includes any Medicaid reimbursable immunosuppressive, anti-infective or other prescriptions necessary for the direct support of organ transplants;

(B)

Some drug classes are subject to restrictions or limitations based upon the Practitioner-Managed Prescription Drug Plan, OAR 410-121-0030 (Practitioner-Managed Prescription Drug Plan).

(4)

Reimbursement for covered prescription drugs is limited by the terms and conditions described in this rule. This limited drug benefit provides State-funded reimbursement to pharmacies choosing to participate according to the terms and conditions of this rule:

(a)

The Authority will send SB 5548 clients a letter from the Authority, instead of a Medical Care Identification, which will document their eligibility for this limited drug benefit;

(b)

Retail pharmacies choosing to participate will be reimbursed for covered prescription drugs for the direct support of organ transplants described in subsection (3)(c) of this rule based upon Oregon Medicaid reimbursement levels as specified in the Division’s Pharmaceutical Services Program administrative rules 410-121-0155 (Reimbursement) and 410-121-0160 (Dispensing Fees).

(c)

The Authority pharmacy benefits manager, will process retail pharmacy drug benefit reimbursement claims for SB 5548 clients;

(d)

Mail order reimbursement will be subject to the Authority contract rates;

(e)

Prescription drugs through the CareAssist program will be subject to the Authority contract rates;

(f)

Reimbursement for this limited drug benefit is not subject to the following rules:

(A)

410-120-1230, Client Copayments;

(B)

410-121-0300 (CMS Federal Upper Limits for Drug Payments), Federal Upper Limit (FUL) for prescription drugs.

Source: Rule 410-120-1195 — SB 5548 Population, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1195.

410‑120‑0000
Acronyms and Definitions 410‑120‑0003
OHP Standard Benefit Package 410‑120‑0006
Medical Eligibility Standards 410‑120‑0011
Effect of COVID-19 Emergency Authorities on Administrative Rules 410‑120‑0025
Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence 410‑120‑0030
Children’s Health Insurance Program 410‑120‑0035
Public Entity 410‑120‑0045
Applications for Medical Assistance at Provider locations 410‑120‑0250
Managed Care Entity 410‑120‑1140
Verification of Eligibility and Coverage 410‑120‑1160
Medical Assistance Benefits and Provider Rules 410‑120‑1180
Medical Assistance Benefits: Out-of-State Services 410‑120‑1190
Medically Needy Benefit Program 410‑120‑1195
SB 5548 Population 410‑120‑1200
Excluded Services and Limitations 410‑120‑1210
Medical Assistance Benefit Packages and Delivery System 410‑120‑1260
Provider Enrollment 410‑120‑1280
Billing 410‑120‑1285
Recoupment and Data Sharing with Third-Party Insurers 410‑120‑1295
Non-Participating Provider 410‑120‑1300
Timely Submission of Claims 410‑120‑1320
Authorization of Payment 410‑120‑1340
Payment 410‑120‑1350
Buying-Up 410‑120‑1360
Requirements for Financial, Clinical and Other Records 410‑120‑1380
Compliance with Federal and State Statutes 410‑120‑1385
Compliance with Public Meetings Law 410‑120‑1390
Premium Sponsorships 410‑120‑1395
Program Integrity 410‑120‑1396
Provider and Contractor Audits 410‑120‑1397
Recovery of Overpayments to Providers — Recoupments and Refunds 410‑120‑1400
Provider Sanctions 410‑120‑1460
Type and Conditions of Sanction 410‑120‑1510
Fraud and Abuse 410‑120‑1560
Provider Appeals 410‑120‑1570
Claim Re-Determinations 410‑120‑1580
Provider Appeals — Administrative Review 410‑120‑1600
Provider Appeals — Contested Case Hearings 410‑120‑1855
Client’s Rights and Responsibilities 410‑120‑1860
Contested Case Hearing Procedures 410‑120‑1865
Denial, Reduction, or Termination of Services 410‑120‑1870
Client Premium Payments 410‑120‑1875
Agency Hearing Representatives 410‑120‑1880
Contracted Services 410‑120‑1920
Institutional Reimbursement Changes 410‑120‑1940
Interest Payments on Overdue Claims 410‑120‑1960
Payment of Private Insurance Premiums 410‑120‑1980
Requests for Information and Public Records 410‑120‑1990
Telehealth
Last Updated

Jun. 8, 2021

Rule 410-120-1195’s source at or​.us