OAR 410-151-0002: Coverage Requirements

(1) The coverage requirements for services to EPSDT Beneficiaries set forth in this Rule supersede any other coverage standards or requirements set forth in any other Medical Assistance rules that are applicable to non-EPSDT Beneficiaries, regardless of whether the other standards or requirements conflict or are otherwise inconsistent with the EPSDT coverage requirements in this Rule. (2) The Oregon Health Authority (the Authority) and Managed Care Entities (MCEs) must cover services that are EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) for EPSDT Beneficiaries, even if: (a) The services are not included or paired on the Prioritized List of Health Services (defined in OAR 410-120-0000); or (b) The service is below the funding line on the Prioritized List of Health Services. (3) The Authority and MCEs may not deny coverage of services for EPSDT Beneficiaries without a case-by-case review for EPSDT Medical Necessity and EPSDT Medical Appropriateness (or EPSDT Dental Appropriateness). It is allowable for services to be denied for EPSDT Beneficiaries after a case-by-case review in which it is determined by the Authority or the MCE that the service is not EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) for that specific EPSDT Beneficiary. Specific circumstances in which the Authority and MCEs may deny coverage of services for an EPSDT Beneficiary are outlined in a guidance document, effective January 1, 2023, available at https://www.oregon.gov/oha/hsd/ohp/pages/epsdt.aspx. (4) The Authority and MCEs must cover Durable Medical Equipment for EPSDT Beneficiaries in accordance with sections (1) through (3) of this rule and OAR 410-122-0010 through OAR 410-122-0720. (5) Providers must not refuse to render or refer for EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) care. Coverage decisions must be made by the Authority or the MCE in accordance with the requirements in sections (1) through (4) of this rule and any denial of coverage must be provided in writing by the Authority or the MCE in accordance with the requirements in OAR 410-151-0007.