Eligibility for Transplant Services
(1)To be eligible for transplant services the client must be on the Basic Health Care Package at the time the transplant services are provided.
(2)Clients covered under the following Benefit Packages do not have coverage for transplants:
(a)Limited Benefit Package (LMH, LMM) — coverage only for mental health, alcohol/drug, pharmacy, and medical transportation services;
(b)Qualified Medicare Beneficiary (MED) — coverage only for services covered by Medicare;
(c)Citizen/Alien-Waived Emergency Medical (CAWEM) — Federal rules exclude coverage of transplants, even if emergent.
(3)If an individual is not eligible for the Basic Health Care Package at the time the transplant is performed, but is later made retroactively eligible for the Basic Health Care Package, the Division of Medical Assistance Programs (Division) will apply the same criteria found in OAR 410-124-0020 (Prior Authorization for All Covered Transplants, Except Cornea and Kidney) through OAR 410-124-0160 (Cornea Transplants) in determining whether to cover the transplant and transplant-related services. Payment can only be made for services provided during the period of time the individual is eligible.
(4)The Division prior authorization is valid for transplant services provided only while the client is enrolled under fee-for-service or a Primary Care Case Manager. If a client moves from the fee-for-service arena to a Fully Capitated Health Plan (FCHP), any prior authorizations which had been approved by the Division are void and prior authorization must be obtained from the new FCHP. If a client moves out of an FCHP into another FCHP, or into fee-for-service, any prior authorizations approved by the original FCHP or Division are void, and prior authorization must again be obtained from the new FCHP or the Division.
Rule 410-124-0010 — Eligibility for Transplant Services,