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As of January 1, 2024, Medicare is the primary payer for the following behavioral health services provided to Medicare members:
- Behavioral health services rendered by Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) as defined by the Centers for Medicare & Medicaid Services (CMS).
- Intensive Outpatient Program (IOP) services furnished by hospital outpatient departments, community mental health centers, rural health clinics, federally qualified health centers, or opioid treatment programs.
Why is this happening?
The Mental Health Access Improvement Act expanded Medicare coverage to include these BH professionals in Medicare coverage services as of January 1, 2024. The Medicare Learning Network’s guide to Medicare and Mental Health Coverage includes details on these changes to coverage, reimbursement and eligible provider types.
What should you do?
MFT and MHC providers who meet federal education and experience requirements should enroll in Medicare.
Clinics and programs with newly Medicare-eligible providers rendering behavioral health services should ensure all applicable staff enroll in Medicare and bill Medicare as primary coverage as Medicaid is the payer of last resort.
Behavioral health services billing tips:
- Bill Medicare as primary for OHP members with the BMM or BMD benefit package. You can verify this coverage in the MMIS Provider Portal.
- For members with Medicare Advantage, communicate with the plans prior to rendering services for any authorization or process required.
- Once you bill for Medicare fee-for-service members, claims automatically crossover to CCOs or OHA. The CCO or OHA then covers cost-sharing amounts from Medicaid for Qualified Medicare Beneficiaries (BMM, MED).
- To learn more about billing, review the OHP Keys to Success manual, dual eligible guidance from CMS, and OHP crossover claim guidance. Contact the member’s CCO for any information on billing or BH wraparound payments.
CCOs:
- Share Medicare requirements with behavioral health providers.
- If you receive a claim that bills OHP instead of Medicare as primary, verify the provider’s Medicare enrollment in PECOS before denying payment.
- Update your claims processing system to no longer automatically bypass the requirement for the provider to first bill Medicare for the newly Medicare eligible behavioral health provider types.
- Ensure your systems pay crossover claims up to the contract allowable. Refer to OAR 410-141-3565.
- Apply behavioral health wraparound payments to crossover claims when applicable. Refer to OHP criteria in CCO contracts.
Questions?
On April 18, 2024, OHA approved Uber’s application to participate in Oregon’s TNC Pilot. CCOs and their Non Emergency Medical Transportation (NEMT) brokerages may start utilizing Uber as part of this pilot.
What should you do?
CCOs and their NEMT brokerages are now permitted to connect with Uber to establish agreements and processes for utilizing the TNC. Please review OHA’s fact sheet to learn more about the pilot and OHA’s expectations for participating brokerages.
Questions?
Please contact Awab Al-Rawe (503-509-9743).
More than one million people are keeping their Oregon Health Plan benefits due to Oregon’s efforts to expand coverage options
At this point in the PHE unwinding process:
- Just 1,078 members, about 0.07 percent, still need to respond to renewal requests 9,573 members, about 0.65 percent, have responded to their renewal but are awaiting state action on the response.
- The remaining renewals, about 8.72 percent of the total, will occur over the summer.
Remaining renewals
Renewal letters will be sent to members in four waves between June and September. Members will still have 90 days to respond, and 60 days’ advance notice before any termination or reduction in benefits. This means the final responses would be due in December 2024, and the final closures will happen in February 2025.
April OHP renewal data
As of March 19, 2024, 1,317,810 people have completed the renewal process. This represents 90.6 percent of all OHP and Medicaid members.
- 1,077,765 people (81.8 percent) were renewed and kept their benefits.
- 226,042 people (17.2 percent) were found ineligible.
- 14,003 people (1.1 percent) had a reduction in their benefits. Most of these members lost full OHP but were able to continue Medicare Savings Programs that help pay their Medicare costs.
OHA has updated its fee-for-service claim system to reflect the rate for substance use disorder (SUD) residential treatment services provided at ASAM Level 3.7 R. The April 2024 Behavioral Health Fee Schedule now reflects the new services.
OHA will reimburse this level of services at $647.00 per day using codes H0018 (up to 30 days of service) and H0019 (beginning day 31) for certified SUD residential treatment providers enrolled with Oregon Medicaid.
Why is this happening?
Oregon is adding reimbursement for ASAM Level 3.7 R as part of the continuum of care described in Oregon’s SUD 1115 Demonstration Waiver.
What should you do?
Update provider reimbursement schedules and contracts as applicable to reimburse for Level 3.7 R services as described above.
Questions?
- Please contact your Account Representative.
- 1:30 to 3:30 p.m., May 2, 2024 - RAC and Community Listening Session
- 1 to 1:55 p.m., April 29, 2024
- 10:05 a.m. to 12 p.m., May 3, 2024
Learn more about these RACs and the rulemaking process.
April 29, 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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