OAR 410-124-0000
Transplant Services
(1)
The Division of Medical Assistance Programs (Division) will make payment for prior authorized and emergency transplant services identified in these rules as covered for eligible clients receiving the OHP Plus benefit package and when the Division transplant criteria described in OAR 410-124-0010 (Eligibility for Transplant Services) and 410-124-0060 (Criteria and Contraindications for Heart Transplants) through 410-124-0160 (Cornea Transplants) is met. All other Benefit Packages do not cover transplant.(2)
The Division will only prior authorize and reimburse for transplants if:(a)
All Division criteria are met; and(b)
Both the transplant center’s and the specialist’s evaluations recommend that the transplant be authorized; and(c)
The ICD-10-CM diagnosis code(s) and CPT transplant procedure code(s) are paired on the same currently funded line on the Prioritized List of Health Services adopted under OAR 410-141-0520.(3)
Simultaneous multiple organ transplants are covered only if specifically identified as paired on the same currently funded line on the Oregon Health Plan (OHP) Prioritized List of Health Services whether the transplants are for the same underlying disease or for unrelated, but concomitant, underlying diseases.(4)
Not Covered Transplant Services: The following types of transplants are not covered by the Division:(a)
Transplants which are considered experimental or investigational or which are performed on an experimental or investigational basis, as determined by the Division;(b)
Transplant services which are contraindicated, as described in OAR 410-124-0060 (Criteria and Contraindications for Heart Transplants) through 410-124-0160 (Cornea Transplants);(c)
Transplants which have not been prior authorized for payment by the Division or the client’s managed health care plan;(d)
Transplants which do not meet the guidelines for an emergency transplant in OAR 410-124-0040 (Emergency Transplants);(e)
Transplants which are not described as covered in OAR 410-141-0480 and 410-141-0520.(5)
Selection of Transplant Centers: Transplant services will be reimbursed only when provided in a transplant center that provides quality services, demonstrates good patient outcomes and compliance with all Division facility criteria. The transplant center must have provided transplant services for a period of at least two years and must have completed a minimum of 12 cases in the most recent year. The patient-and-graft-survival rates must be equal to or greater than the appropriate standard indicated in this rule. A transplant center which has had at least two years of experience in transplantation of any solid organ (heart, liver, lung, pancreas) and which has met or exceeded the appropriate standards may be considered for reimbursement for the transplantation of other solid organs and/or autologous or allogeneic bone marrow transplantation:(a)
An experienced and proficient transplant team and a well established transplant support infrastructure at the same physical location as the transplant service is required for transplant services rendered to Division clients. These transplant criteria are crucial to successful transplant outcome. Therefore, consortia will not be approved or contracted with for the provision of transplant services for Division clients. No Division transplant contract, prior approval or reimbursement will be made to consortia for transplant services where, as determined by the Division, there is no assurance that the individual facilities that make up the consortia independently meet Division criteria. The Division’s transplant criteria must be met individually by a facility to demonstrate substantial experience with the procedure;(b)
Once a transplant facility has been approved and contracted for Division transplant services, it is obliged to report immediately to the Division any events or changes that would affect its approved status. Specifically, a transplant facility is required to report, within a reasonable period of time, any significant decrease in its experience level or survival rates, the departure of key members of the transplant team or any other major changes that could affect the performance of transplants at the facility. Changes from the terms of approval may lead to prospective withdrawal of approval for Division coverage of transplants performed at the facility;(c)
Coordinated care organizations (CCOs) that contract with non-Division contracted facilities for OHP Plus clients will develop and use appropriate transplant facility criteria to evaluate and monitor for quality services at the transplant facility;(d)
Transplant centers which have less than two years’ experience in solid organ transplant may be reimbursed, at the Division’s discretion, for allogeneic or autologous bone marrow transplants upon completion of two years of experience in bone marrow transplantation with patient survival rates equal to or exceeding those defined in section (5) of this rule;(e)
The Division will discontinue the contract with a transplant center when the graft and/or survival rates fall below the standards indicated in this rule for a period of two consecutive years.(6)
Standards for Transplant Centers:(a)
Heart, heart-lung and lung transplants:(A)
Heart: One-year patient survival rate of at least 80%;(B)
Heart-Lung: One-year patient survival rate of at least 65%;(C)
Lung: One-year patient survival rate of at least 65%.(b)
Bone Marrow (autologous and allogeneic), peripheral stem cell (autologous and allogeneic) and cord blood (allogeneic) transplants: One-year patient survival rate of at least 50%;(c)
Liver transplants: One year patient survival rate of at least 70% and one year graft survival rate of at least 60%;(d)
Simultaneous pancreas-kidney and pancreas-after-kidney transplants: One year patient survival rate of at least 90% and one year graft survival rate of at least 60%;(e)
Kidney transplants: One year patient survival rate of at least 92% and one year graft survival rate of at least 85%.(7)
Selection of transplant centers by geographic location: If the services are available in the state of Oregon, reimbursement will not be made to out-of-state transplant centers. Out-of-state centers will be considered only if:(a)
The type of transplant required is not available in the state of Oregon and/or the type of transplant (for example, liver transplant) is available in the state of Oregon but the Oregon transplant center does not provide that type of transplant for all clients or all covered diagnoses, (e.g., pediatric transplants); and(b)
An in-state transplant center requests the out-of-state transplant referral; and(c)
An in-state transplant facility recommends transplantation based on in-state facility and Division criteria; or(d)
It would be cost effective as determined by the Division. For example, if the transplant service is covered by the client’s benefit package and the client’s primary insurer (i.e., Medicare) requires the use of an out-of-state transplant center; or(e)
It is a contiguous, out-of-state transplant center that has a contract or special agreement for reimbursement with the Division.(8)
Professional and other services will be covered according to administrative rules in the applicable provider guides.(9)
Reimbursement for covered transplants and follow-up care for transplant services is as follows:(a)
For transplants for fee-for-service clients:(A)
Transplant facility services — by contract with the Division;(B)
Professional services — at the Division’s maximum allowable rates.(b)
For emergency services, when no special agreement has been established, the rate will be:(A)
75% of standard inpatient billed charge; and(B)
50% of standard outpatient billed charge; or(C)
The payment rate set by the Medical Assistance program of the state in which the center is located, whichever is lower.(c)
For clients enrolled in CCOs, reimbursement for transplant services will be by agreement between the CCO and the transplant center.
Source:
Rule 410-124-0000 — Transplant Services, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-124-0000.