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In January 2022, the Oregon Health Authority (OHA) notified providers and CCOs that pharmacy claims for federally supplied COVID-19 therapeutics1 should be billed to OHA for all Oregon Health Plan (OHP) members. This policy is no longer in effect since there are no longer federally supplied therapeutics, only commercially supplied.
OHA has decided to apply the “No Wrong Door” policy, which currently applies to COVID-19 vaccine and vaccine administration expenses for CCO members, to commercially supplied COVID therapeutics. This decision is retroactively effective to January 1, 2024. Under this policy, if a provider is not contracted by the CCO, then the provider should bill OHA for the medication and dispensing fee.
OHA made this decision to ensure that all OHP members can access COVID therapeutics without the need for Prior Authorization (PA), which CCOs can choose to require for non-contracted providers.
With respect to the retroactive effective date for the “No Wrong Door” policy for COVID-19 therapeutics:
- If the CCO requires PA for non-contracted providers, then the CCO must honor its PA and pay the provider’s Valid Claim if the PA was approved prior to the date of this communication.
- If the CCO does not require PA for non-contracted providers, then the CCO must pay the provider’s Valid Claim if it was received prior to the date of this communication.
CCOs remain responsible for paying contracted providers for COVID-19 therapeutics.
The “No Wrong Door” policy as applied to COVID-19 therapeutics for CCO members will continue through 9/30/2024. This date aligns with the last day for the “No Wrong Door” as applied to COVID vaccine and vaccine administration expenses for CCO members.
Each CCO will decide whether to require non-contracted providers to obtain PA for COVID-19 therapeutics beginning 10/1/2024. OHA expects each CCO to widely communicate its requirements well in advance of this date.
CCOs should continue to monitor OHA communications about COVID-19 reimbursement and coverage to ensure they are applying the most current information.
We are working on developing a process for CCOs to request capacity increases to their member enrollments; as well as strategically plan for possible plan closures in counties that are over capacity.
On Monday, we are hosting a virtual drop-in session from 9:15-10:30 a.m. (you do not need to attend the full time) for staff to share their thoughts, concerns, and questions about this process.
Questions we will address include:
- How do CCOs prefer to make capacity increase requests (such as form, email, other?)
- What information is critical to include? What would be unnecessary or burdensome?
- What information is already available to you or being sent to OHA that we can access for making determinations around capacity increases? -
- What would a denial or county being closed to enrollment look like?
- Short vs long-term closure, re-enrollment options, coordination with FFS or other CCOs
- What communications do your staff need to be able to talk to members or potential members?
- What are the possible ramifications to members?
- o Are there populations or circumstances where exceptions should be made?
- o Health equity concerns?
- What else is important to plan for? What do you need for us to support you?
Questions about the meeting or the process? Please reach out to Dana Carly at dana.mitschnelson@oha.oregon.gov
Join the drop-in session on Monday, March 18 from 9:15 a.m. to 10:30 a.m.
As OHA continues to collaborate with OCEACT on making all necessary updates to all the resource tools, training materials and fidelity scale per the updated Oregon Administrative Rules (OAR) that took effect 01/01/24; The Division will continue pausing all ACT fidelity reviews into the second quarter of 2024 (April-June). The fidelity reviews that would normally occur during this time will not need to be rescheduled. The certifications for these programs will be extended.
Please continue attending the monthly Learning Collaborative that OHA’s hosts for most recent updates and remain in communication with OCEACT to ensure technical assistance is received. We appreciate all the engagement and patience from ACT programs during this transition to improve the system as a whole and your dedication to the people in your communities.
If you have any questions or concerns about this, please reach out to Angella
James at angella.pulkownik2@oha.oregon.gov or 503-367-6414.
The 2024 Legislative session has come to an end!
During the 2024 short session 288 bills were introduced in the legislature. Of those bills, OHA actively tracked 124 as they moved through the legislative process. Here is a summary of major health-related bills, provided by OHA Director Dr. Sejal Hathi to OHA staff on March 11:
Addressing Oregon’s behavioral health crisis and preserving Measure 110 services
Changing Measure 110 was a primary focus of this legislative session. Legislators passed the Oregon Drug Intervention Plan (House Bill 4002) with broad bipartisan support. While the plan recriminalizes drug possession, which will wield disproportionate harms on people of color, it also provides off-ramps to treatment prior to prosecution and conviction and maintains grants for Behavioral Health Resource Networks (BHRNs), which expand access to a range of substance use services that aren’t funded through traditional funding streams.
HB 4002 repeals the Class E violation that previously applied to possession of small amounts of a controlled substance and replaces it with a new misdemeanor crime, effective September 1, of unlawful possession of a controlled substance. It encourages but does not require counties to operate deflection programs that provide opportunities for substance users to complete treatment instead of being prosecuted. It also:
- Directs OHA to establish and expand the Certified Community Behavioral Health Clinic model. These clinics provide primary care integrated with comprehensive mental health and substance use disorder services and 24/7 crisis care to all no matter their diagnosis or insurance status.
- Creates a grant program to support opioid use disorder services in local and Tribal correctional facilities.
- Prohibits insurers and coordinated care organizations (CCOs) from requiring prior authorization of medications for substance use disorders.
- Directs the Alcohol and Drug Policy Commission to conduct a study related to barriers and best practices for serving youth with substance use disorders.
- Establishes the United We Heal Medicaid Payment Program in OHA to bolster the behavioral health workforce.
- Forms a Joint Task Force on Regional Behavioral Health Accountability.
HB 5204 invests $221.2 million in grants and activities related to HB 4002, including one-time funding of $3.2 million to OHA for the Nurse-Family Partnership. These funds will be critical to our efforts to stem the substance use disorder epidemic and reduce health inequities.
Our HB 4002 and HB 5204 fact sheet provides more details about these investments and OHA’s role in implementing these bills in ways that advance health equity. The legislature passed other bills late in session that will also address behavioral health in Oregon:
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Senate Bill (SB) 1557 —Directs OHA and Oregon Department of Human Services (ODHS) to use substantial federal funds to provide kids with complex health needs access to medically appropriate care — including behavioral health care — at home and in the community. It also directs OHA and ODHS to make recommendations to implement a policy to disregard parental income for those children and youth who meet eligibility criteria for these services.
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HB 4150 — Allows OHA, in certain circumstances, to use the Prescription Drug Monitoring Program to provide electronic notification to a practitioner when their patient has had a fatal or nonfatal overdose.
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HB 4092 — Requires OHA to study how much funding community mental health programs (CMHPs) need to provide required services. It also directs OHA to fund the Oregon Behavioral Health Council to conduct a study related to the burden of administrating local behavioral health programs.
Addressing access to care
The Legislature also enacted several bills that will advance our 2030 goal by expanding access to interpreters, cooling devices, the nursing workforce, and prescription drug benefits.
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SB 1508 — Directs the Health Evidence Review Commission (HERC) and Pharmacy and Therapeutics Committee (P&T) to prevent disability-related discrimination by eliminating any use of or influence from analytic tools such as Quality-Adjusted Life Years (QALYs) from the decision-making process. The bill also limits copays or cost-sharing for insulin to $35 for a 30-day supply or $105 for a 90-day supply.
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HB 4081 — Establishes the Emergency Management System (EMS) program under OHA, as well as four advisory committees focused on developing a fully coordinated, integrated approach to the treatment of time-sensitive medical emergencies.
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SB 1578 — Directs OHA to contract with a nonprofit entity to develop and administer a Health Care Interpreter Recruitment and Retention Program and requires OHA to establish and maintain an online interpreter management system.
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SB 1529 — Authorizes OHA and community partners to distribute air conditioners and air filters during an emergency. This bill will help OHA provide 4,000 air conditioners to eligible Oregonians in the Medicaid fee-for-service program. This is in addition to the estimated 1,300 air conditioners the fee-for-service program will provide to specific transition populations through the 1115 waiver climate supports program.
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HB 4113 — Changes the insurance code to ensure that pharmaceutical coupons and discounts apply towards patients’ out-of-pocket costs and deductibles to reach their out-of-pocket maximum sooner. Due to this legislation, many people in Oregon will pay less out of pocket for prescription drugs, since once these maximums are reached the insurer would be responsible for covering the costs of care.
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HB 4136 — Directs OHA to distribute $4.5 million to Lane County Public Health to fund emergency medical care, a basic life support unit, as well as a health care access innovation fund, to improve access to same-day health services while decreasing costs in the wake of the closure of Eugene’s only hospital last year. The bill also streamlines licensing timelines for nurses who move from other states with active licenses in good standing.
Expanding access to safe and affordable housing across Oregon
Legislators approved key initiatives that support Governor Kotek’s priority to reduce homelessness through passage of the Emergency Housing Stabilization and Production Package that provides a $376 million state investment in addressing the housing crisis. This important package aligns with OHA’s efforts to address this critical social determinant of health.
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SB 1530 appropriates $279.6 million across eight state agencies to support investments in affordable housing production, climate impacts, shelter operations, homelessness prevention, and tenant education and navigation. OHA will receive $36.5 million directly to support grants to housing providers to serve people in recovery from substance use disorder ($18 million), as well as a direct investment in the Healthy Homes Fund ($15 million).
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SB 1537 appropriates $89.5 million to help stabilize housing costs by increasing housing production through removing red tape in permitting processes, establishing some of the strongest affordability standards for new construction in the country, and other critical reforms.
OHA legislative reports will be posted to the Government Relations page.
Updated guidance documents will be posted on the In Lieu of Services (ILOS) page by 5 p.m. today.
For previous guidance, please see the CCO Contract Forms page.
- 9 to 10:30 a.m., March 26, 2024
- 1 to 2:30 p.m., March 28, 2024 for Portland Metro PSRB Providers
- 10 to 11:30 a.m., March 29, 2024 for I-5 PSRB Providers
- 9:30 to 11 a.m., April 1, 2024 for Rural County PSRB Providers
- 10:30 a.m. to 12 p.m., April 2, 2024 for Rural County PSRB Providers
- 10:30 to 11:30 a.m., April 4, 2024 for PSRB and OSH
- 1 to 2:30 p.m., April 5, 2024 for Additional/Makeup session
- 10 to 11:30 a.m., March 19, 2024
- 10:30 to 12 p.m., March 21, 2024
- 3 to 5 p.m., March 28, 2024
- 3:30 to 5 p.m., April 15, 2024
Learn more about these RACs and the rulemaking process.
March 18, 2024
March 20, 2024
Please visit the committee and workgroup links below for more information about meetings. You can also view the OHA Public Meeting calendar.
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