OAR 410-125-0045: Temporary rule language in effect until 12/27/2026. Coverage and Limitations

In general, most medically necessary and appropriate services are covered. There are, however, some restrictions and limitations. Please refer to the Oregon Administrative Rules (OAR) in Chapter 410, Division 120 and the Oregon Health Authority’s (Authority) other Medical Assistance OARs found in Chapter 410 for information on general scope of coverage and limitations. Some of the limitations and restrictions that apply to hospital services are: (1) Prior authorization (PA): Some services require PA for the Oregon Health Plan (OHP) Plus Benefit Package. In order to determine which services require PA for the OHP Plus Benefit Package, refer to OAR 410-125-0080. (2) Non-covered services: (a) Services that are not medically necessary and appropriate, unproven medical efficacy or services that are the responsibility of another Department of Human Services (Department) or Oregon Health Authority (Authority) are not covered by the Authority’s Medical Assistance Programs; (b) Service coverage is based on the Health Evidence Review Commission's (HERC) Prioritized List of Services and the client’s benefit package; (c) See the general rules for the Authority’s Medical Assistance Programs (chapter 410, division 120) and other program divisions in chapter 410 for a list of services that are not covered. Further information on covered and non-covered services is found in the Revenue Code section in the Hospital Services Supplemental Information on the Oregon Health Authority’s Health Systems Division’s webpage. (3) Limitations on hospital benefit days: Clients have no hospital benefit day limitations for treatment of covered services. (4) Dental services: Clients have dental/denturist services identified as covered on the HERC Prioritized List (OAR 410-123-1260). (5) Hospital services provided outside of the hospital's licensed facilities: (a) Services provided in the client's home or in a nursing home, are not covered by the Authority as hospital services; (b) There are a limited number of hospital services that are covered when they are provided outside a hospital’s licensed facility, which include the following: (A) Caring Contacts services (described in OAR 333-520-0700); (B) Maternity Case Management services (described in OAR 410-130-0595); and (C) Specific nursing or physician services provided during a ground or air ambulance transport (described in OAR 410-136-3180).