Oregon Oregon Health Authority, Health Systems Division: Medical Assistance Programs

Rule Rule 410-120-1200
Excluded Services and Limitations


(1)

Certain services or items are not covered under any program or for any group of eligible clients. Service limitations are subject to the Health Evidenced Review Commission (HERC) Prioritized List of Health Services as referenced in 410-141-3830 (Prioritized List of Health Services) and the individual program chapter 410 OARs. If the client accepts financial responsibility for a non-covered service, payment is a matter between the provider and the client subject to the requirements of OAR 410-120-1280 (Billing).

(2)

The Division of Medical Assistance Programs (Division) shall make no payment for any expense incurred for any of the following services or items that are:

(a)

Not expected to significantly improve the basic health status of the client as determined by Division staff or its contracted entities; for example, the Division’s medical director, medical consultants, dental consultants, or Quality Improvement Organizations (QIO);

(b)

Determined not medically or dentally appropriate by Division staff or authorized representatives, including DMAP’s contracted utilization review organization, or are not covered by the Health Evidence Review Commission Prioritized List of Health Services;

(c)

Not properly prescribed as required by law or administrative rule by a licensed practitioner practicing within his or her scope of practice or licensure;

(d)

For routine checkups or examinations for individuals age 21 or older in connection with participation, enrollment, or attendance in a program or activity not related to the improvement of health and rehabilitation of the client. Examples include exams for employment or insurance purposes;

(e)

Provided by friends or relatives of eligible clients or members of his or her household, except when the friend, relative or household member:

(A)

Is a health professional acting in a professional capacity; or

(B)

Is directly employed by the client under the Department of Human Services (Department) Aging and People with Disabilities division (APD) Home and Community Based Services or the APD administrative rules, OAR 411-034-0000 (Purpose) through 411-034-0090 (Payment Limitations), governing Personal Care Services covered by the State Plan; or

(C)

Is directly employed by the client under the Department Child Welfare administrative rules, OAR 413-090-0100 (Purpose) through 413-090-0220, for services to children in the care and custody of the Department who have special needs inconsistent with their ages. A family member of a minor client (under the age of 18) must not be legally responsible for the client in order to be a provider of personal care services;

(f)

For services or items provided to a client who is in the custody of a law enforcement agency or an inmate of a non-medical public institution, including juveniles in detention facilities, except such services as designated by federal statute or regulation as permissible for coverage under the Division’s administrative rules (i.e., inpatient hospitalizations);

(g)

Needed for purchase, repair, or replacement of materials or equipment caused by adverse actions of adult clients age 21 and over to personally owned goods or equipment or to items or equipment that the Division rented or purchased;

(h)

Related to a non-covered service; some exceptions are identified in the individual provider rules. If the Division determines the provision of a service related to a non-covered service is cost effective, the related medical service may, at the discretion of the Division and with Division prior authorization (PA), be covered;

(i)

Considered experimental or investigational, including clinical trials and demonstration projects, or that deviates from acceptable and customary standards of medical practice or for which there is insufficient outcome data to indicate efficacy;

(j)

Identified in the appropriate program rules including the Division’s Hospital Services program administrative rules, Revenue Codes Section, as non- covered services.

(k)

Requested by or for a client whom the Division has determined to be non-compliant with treatment and who is unlikely to benefit from additional related, identical, or similar services;

(l)

For copying or preparing records or documents, except those Administrative Medical Reports requested by the branch offices or the Division for casework planning or eligibility determinations;

(m)

Whose primary intent is to improve appearances, exceptions subject to the HERC coverage and guidelines;

(n)

Similar or identical to services or items that will achieve the same purpose at a lower cost and where it is anticipated that the outcome for the client will be essentially the same;

(o)

For the purpose of establishing or reestablishing fertility or pregnancy;

(p)

Items or services that are for the convenience of the client and are not medically or dentally appropriate;

(q)

The collection, processing, and storage of autologous blood or blood from selected donors unless a physician certifies that the use of autologous blood or blood from a selected donor is medically appropriate and surgery is scheduled;

(r)

Educational or training classes that are not intended to improve a medical condition;

(s)

Outpatient social services except maternity case management services and other social services described as covered in the individual provider rules;

(t)

Post-mortem exams or burial costs;

(u)

Radial keratotomies

(v)

Recreational therapy;

(w)

Telephone calls except for:

(A)

Tobacco cessation counseling as described in OAR 410-130-0190 (Tobacco Cessation);

(B)

Maternity case management as described in OAR 410-130-0595 (Maternity Case Management);

(C)

Telemedicine as described in OAR 410-130-0610; and

(D)

Services specifically identified as allowable for telephonic delivery when appropriate in the mental health and substance use disorder procedure code and reimbursement rates published by the Addiction and Mental Health division;

(x)

Services that have no standard code set as established according to 45 CFR 162.1000 to 162.1011, unless the Division has assigned a procedure code to a service authorized in rule;

(y)

Whole blood (Whole blood is available at no cost from the Red Cross.); The processing, storage, and costs of administering whole blood are covered;

(z)

Immunizations prescribed for foreign travel;

(aa)

Services that are requested or ordered but not provided to the client, unless specified otherwise in individual program rules;

(bb)

Missed appointments, an appointment that the client fails to keep. Refer to 410-120-1280 (Billing);

(cc)

Transportation to meet a client’s personal choice of a provider;

(dd)

Alcoholics Anonymous (AA) and other self-help programs;

(ee)

Medicare Part D covered prescription drugs or classes of drugs and any cost sharing for those drugs for Medicare-Medicaid Fully Dual Eligible clients, even if the Fully Dual Eligible client is not enrolled in a Medicare Part D plan. See OAR 410-120-1210 (Medical Assistance Benefit Packages and Delivery System) for benefit package;

(ff)

Services provided outside of the United States. Refer to OAR 410-120-1180 (Medical Assistance Benefits: Out-of-State Services).
Source

Last accessed
Jun. 8, 2021