OAR 333-022-1080: CareAssist: Payments and Cost Coverage

(1) The Authority may only make insurance premium payments directly to the insurance carrier or benefits administrator. No direct payments may be made to a client. (2) When no other payer for health coverage (public assistance or private) is available, CAREAssist may pay insurance premiums for a limited time for a client’s insurance plan that covers his or her family members if the monthly premium cannot by divided, until the Authority determines that the client’s family members can obtain their own policies. (3) The Authority may not use CAREAssist funds to pay for any administrative costs, which are in addition to the premium payment. (4) Authority payments for prescriptions follow the health insurance pharmacy benefits defined within the policy and may not pay for the cost to dispense a brand-name drug when a generic equivalent is the preferred option of the health insurance. (5) The Authority shall only cover the costs of medications that are covered by the client’s health insurance or those specifically listed on the CAREAssist formulary as additional benefits to the client, and prior to any payments being made by the Authority must receive a determination by the prescriber that no acceptable therapeutic equivalent is available through the primary insurance. (6) The Authority may only pay for HIV medications or a combination of HIV drugs as approved in the federal Department of Health and Human Services (DHHS) Treatment Guidelines, which can be found at http://aidsinfo.nih.gov/guidelines. (a) The CAREAssist Pharmacy Benefits Manager (PBM) clinical pharmacist team (team) assesses each client’s medication regimen to ensure that it conforms to current DHHS guidelines. In the event that a treatment recommendation or guideline is not followed, the clinical pharmacist at the PBM shall notify the Authority that payment may not be made until the prescriber submits a prior authorization form to the PBM’s clinical pharmacist. (b) The Authority may deny payment for medications that are determined to be clinically inappropriate pursuant to the DHHS Treatment Guidelines. (7) Medical Services. (a) The Authority shall identify and inform clients of an amount to be provided within the calendar year for medical service copays and deductible. The annual financial amount shall be posted on the CAREAssist website at the beginning of each calendar year. All costs exceeding the published amount are the client’s responsibility. (b) The Authority may pay for a client’s out-of-pocket medical service expense for an insurance-covered medical service or durable medical equipment, up to an annual maximum amount. The client’s primary insurance must cover the service or device before CAREAssist assumes any financial cost unless the client is pre-approved for limited full-cost coverage under UPP or Bridge, as allowed under OARs 333-022-1140 and 333-022-1145. (8) When the Authority acts as primary payer: (a) Reimbursement to providers shall be 125 percent of the current Oregon Medicaid Fee for Service rate for the allowable Current Procedural Terminology (CPT) Code unless the provider bills for less. A list of allowable CPT Codes is posted on the CAREAssist website. (b) Payments made by the Authority on behalf of clients must be accepted by the provider as payment in-full. Balance billing is prohibited. (9) Clients who receive refunds for services paid by the Authority on the client’s behalf must reimburse the program or develop a repayment plan within 60-days of receiving the refund. This includes but is not limited to refunds issued by pharmacies, medical providers, insurance carriers and the Internal Revenue Service.