OAR 333-006-0180: Health Benefit Plan Reimbursement Requirements

(1) As used in OAR 333-006-0180 through 333-006-0190 the following definitions apply: (a) "Billing guidance" means a document describing the claim submission process. (b) "Budget standards" means a document describing standardized and allowable expenses included in the determination of the case rate for newborn nurse home visiting services, including Community Lead Service Requirements outlined in OAR 333-006-0050 and Newborn Nurse Home Visiting Provider and Service Requirements outlined in OAR 333-006-0100 through 333-006-0130. (c) "Case rate" means a flat fee paid for newborn nurse home visiting services. The case rate includes all newborn nurse home visiting services, including Community Lead Service Requirements outlined in OAR 333-006-0050 and Newborn Nurse Home Visiting Provider and Service Requirements outlined in OAR 333-006-0100 through 333-006-0130. The case rate is also known as a bundled claim. (d) "Single support visit rate" means a one-time flat fee paid when a support visit, as defined in OAR 333-006-0010(17), is completed prior to a comprehensive newborn nurse home visit and the comprehensive newborn nurse home visit is subsequently not completed. (e) "Template" means the document the Oregon Health Authority (Authority) shall provide to each newborn nurse home visiting provider and community lead in order to document costs related to providing newborn nurse home visiting services. The template will reflect the budget standards. (2) Health benefit plans must reimburse the newborn nurse home visiting provider at the case rate for these services as defined in ORS 743A.078. (3) The case rate and the single support visit rate on July 1, 2023, and thereafter shall be determined by a cost study coordinated by the Authority in consultation with an advisory committee on a biennial schedule. The case rate will be effective on July 1 of odd numbered calendar years. (a) The advisory committee will advise the Authority on development of the case rate. Documents used to determine the case rate will include but are not limited to the budget standards, the template and the billing guidance. The advisory committee will include representatives of health benefit plans, newborn nurse home visiting providers and community members. The advisory committee shall not exceed 10 members. Members shall be selected via an application process developed by the Authority. (b) Each newborn nurse home visiting provider and community lead must participate in the biennial cost study. The Authority will provide templates to newborn nurse home visiting providers and community leads. (c) The Authority will review newborn nurse home visiting provider and community lead services budgets to determine compliance with budget standards as determined by the Authority and notify providers of any non-compliance with standards. (d) Newborn nurse home visiting providers and community leads shall request a deviation from budget standards based on a compelling modification needed in the designated community. Such a request must be made in writing. (e) The Authority shall determine which budgets meet standards and are included in the cost study. (f) At the conclusion of the cost study, the Authority shall determine the case rate and publish it on Oregon’s Universally Offered Newborn Nurse Home Visiting Program website: www.healthoregon.org/familyconnects.