On June 19, 2020, the federal Department of Health and Human Services published changes to regulations adopted under Section 1557 of the Affordable Care Act (Section 1557). One of the changes was to remove gender identity and sexual orientation from the definition of "sex" in the nondiscrimination requirements of Section 1557.
The Oregon Health Authority (OHA) wants to address questions and concerns about this change.
- This federal change does not change Oregon Health Plan (OHP) coverage for gender-diverse members.
- OHP currently covers gender transition services, such as hormone therapy, counseling and some surgeries. Changes to Section 1557 do not change this coverage.
- OHP coverage guidance is provided by the Health Evidence Review Commission (HERC). Transgender OHP coverage is outlined in HERC Guideline 127.
Coordinated care organizations (CCOs) and providers should continue to provide OHP-covered services in accordance with HERC guidelines and state laws that prohibit discrimination based on gender identity and sexual orientation.
To learn more, please read the announcement from OHA.
Fee-for-service claims for administrative exams and reports to suspend for OHA review
To help the Department of Human Services (DHS) and Oregon Youth Authority (OYA) determine medical eligibility for certain programs, psychiatrists, social workers and other providers complete administrative exams and reports for DHS and OYA review.
Later this year, claims submitted for DHS- and OYA-ordered exams and reports will suspend for manual review. This review will ensure that there is a DHS or OYA Administrative Exam request supporting the submitted claim. OHA will notify affected providers with details soon.
Version 37.1 MS-DRG grouper update, effective April 1, 2020
On June 28, 2020, OHA will update its claims system with Version 37.1 of the Medicare Severity Diagnosis Related Group (MS-DRG) grouper software, effective April 1, 2020.
OHA plans to reprocess all inpatient claims paid on or after April 1, 2020, to ensure the claims comply with this update. When a reprocessing date is confirmed, we will let you know.
To learn more about the changes in Version 37.1 of the MS-DRG grouper, view the "Latest News" on the Centers for Medicare & Medicaid Services MS-DRG website.
As we work toward reopening Oregon, we want to make sure you have the resources you need to keep informed, healthy and safe. If you have any questions about OHP and COVID-19, please let us know.
Updates for Oregon Health Plan providers
No new updates.
Updates for all health care providers
Find COVID-19 testing data, public health guidance, weekly information calls and more resources for all health care partners.
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New Independent and Qualified Agent for Medicaid-covered behavioral health services effective July 1, 2020
Starting July 1, 2020, Comagine Health will be OHA's new Independent and Qualified Agent (IQA). The IQA provides independent assessments and person-centered services planning for Medicaid-eligible individuals who receive:
- 1915(i) Home and Community Based Services (HCBS) State Plan Option services, or
- Non-1915(i) fee-for-service behavioral health services.
Starting July 1, Comagine Health will also provide the following services:
- Assessments and person-centered service planning for individuals in behavioral health residential treatment who are not Medicaid-eligible, and
- Coordination of State Plan Personal Care (also known as PC 20) services.
To learn more, read the announcement from OHA.
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410-120-1280 - Billing Rules: Adding A New Form Number For A Pharmacy-Specific Agreement To Pay Form
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410-120-1340 - Annual Updates; Relative Value Unit (RVU) Weight; Clinical Lab, ASC
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410-121-0030, 410-121-0040 - Amending Preferred Drug List and Prior Authorization Approval Criteria Guide
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410-170-0000, 410-170-0020, 410-170-0030, 410-170-0040, 410-170-0050, 410-170-0060, 410-170-0070, 410-170-0090, 410-170-0100, 410-170-0110 - Updates BRS Rules For Accuracy And Aligns Rule With SB 171 And Family First Act
- 410-170-0080 - Updates Rule For Accuracy And Aligns Rule With SB 171 And Family First Act
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