ORS 414.065: Determination of health services covered; quality measures; reimbursement; cost sharing; payments by Oregon Health Authority as payment in full; rules.
Edition: 2025 EditionEffective: 2026-01-01Last verified: 2026-09-07
(1)(a) Consistent with ORS 414.690, 414.710, 414.712 and 414.766 and other statutes governing the provision of and payments for health services in medical assistance, the Oregon Health Authority shall determine, subject to such revisions as it may make from time to time and to legislative funding: (A) The types and extent of health services to be provided to each eligible group of recipients of medical assistance. (B) Standards, including outcome and quality measures, to be observed in the provision of health services. (C) The number of days of health services toward the cost of which medical assistance funds will be expended in the care of any person. (D) Reasonable fees, charges, daily rates and global payments for meeting the costs of providing health services to an applicant or recipient. (E) Reasonable fees for professional medical and dental services which may be based on usual and customary fees in the locality for similar services. (F) The amount and application of any copayment or other similar cost-sharing payment that the authority may require a recipient to pay toward the cost of health services. (b) The authority shall adopt rules establishing timelines for payment of health services under paragraph (a) of this subsection. (2) In making the determinations under subsection (1) of this section and in the imposition of any utilization controls on access to health services, the authority may not consider a quality of life in general measure, either directly or by considering a source that relies on a quality of life in general measure. (3) The types and extent of health services and the amounts to be paid in meeting the costs thereof, as determined and fixed by the authority and within the limits of funds available therefor, shall be the total available for medical assistance, and payments for such medical assistance shall be the total amounts from medical assistance funds available to providers of health services in meeting the costs thereof. (4) Except for payments under a cost-sharing plan, payments made by the authority for medical assistance shall constitute payment in full for all health services for which such payments of medical assistance were made. (5) Notwithstanding subsection (1) of this section, the Department of Human Services shall be responsible for determining the payment for Medicaid-funded long term care services and for contracting with the providers of long term care services. (6) In determining a global budget for a coordinated care organization: (a) The allocation of the payment, the risk and any cost savings shall be determined by the governing body of the organization; (b) The authority shall consider the community health assessment conducted by the organization in accordance with ORS 414.577 and reviewed annually, and the organization’s health care costs; and (c) The authority shall take into account the organization’s provision of innovative, nontraditional health services. (7) Under the supervision of the Governor, the authority may work with the Centers for Medicare and Medicaid Services to develop, in addition to global budgets, payment streams: (a) To support improved delivery of health care to recipients of medical assistance; and (b) That are funded by coordinated care organizations, counties or other entities other than the state whose contributions qualify for federal matching funds under Title XIX or XXI of the Social Security Act. [1965 c.556 §5; 1967 c.502 §12; 1975 c.509 §5; 1981 c.825 §4; 1987 c.918 §4; 1989 c.836 §21; 1991 c.66 §13; 1991 c.753 §3; 1995 c.271 §1; 1995 c.807 §3; 1999 c.546 §1; 2001 c.875 §1; 2005 c.381 §14; 2005 c.806 §1; 2009 c.595 §276; 2011 c.602 §22; 2012 c.8 §19; 2013 c.534 §1; 2013 c.688 §70; 2019 c.529 §5; 2024 c.18 §1]
Administrative rules citing this section
- OAR 309-018-0162: Residential Specialty Programs — implements
- OAR 407-120-0100: Definitions — implements
- OAR 407-120-0110: Purpose — implements
- OAR 407-120-0112: Scope and Sequence of Electronic Data Transmission Rules — implements
- OAR 407-120-0114: Provider Enrollment Agreement — implements
- OAR 407-120-0116: Web Portal Submitter — implements
- OAR 407-120-0118: Conduct of Direct Data Entry Using Web Portal — implements
- OAR 407-120-0120: Registration Process — EDI Transactions — implements
- OAR 407-120-0130: Trading Partner as EDI Submitter – EDI Transactions — implements
- OAR 407-120-0140: Trading Partner Agents as EDI Submitters — EDI Transactions — implements
- OAR 407-120-0150: Testing — EDI Transactions — implements
- OAR 407-120-0160: Conduct of Transactions — EDI Transactions — implements
- OAR 407-120-0165: Pharmacy Point of Sale Access — implements
- OAR 407-120-0170: Confidentiality and Security — implements
- OAR 407-120-0180: Record Retention and Audit — implements
- OAR 407-120-0190: Material Changes — implements
- OAR 407-120-0200: Department System Administration — implements
- OAR 407-120-0400: MMIS Replacement Communication Plan — implements
- OAR 410-115-0030: OHP Bridge Covered Services. — implements
- OAR 410-115-0050: OHP Bridge - BHP Trust Fund. — implements
- OAR 410-120-0000: Acronyms and Definitions — implements
- OAR 410-120-0000: Acronyms and Definitions — authority
- OAR 410-120-0025: Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence — implements
- OAR 410-120-0035: Public Entity — implements
- OAR 410-120-1140: Verification of Eligibility and Coverage — implements
- OAR 410-120-1180: Medical Assistance Benefits: Out-of-State Services — implements
- OAR 410-120-1200: Excluded Services and Limitations — implements
- OAR 410-120-1221: Fee-for-Service Care Coordination: Identification of Open Card Member Needs — implements
- OAR 410-120-1295: Temporary rule language in effect until 01/16/2027. Non-Participating Provider — implements
- OAR 410-120-1320: Authorization of Payment — implements
- OAR 410-120-1570: Claim Re-Determinations — implements
- OAR 410-120-1580: Provider Appeals — Administrative Review — implements
- OAR 410-120-1600: Provider Appeals — Contested Case Hearings — implements
- OAR 410-121-0000: Foreword and Definition of Terms — implements
- OAR 410-121-0021: Organizations Authorized to Provide Pharmaceutical Prescription Services — implements
- OAR 410-121-0030: Practitioner-Managed Prescription Drug Plan — implements
- OAR 410-121-0032: Supplemental Rebate Agreements — implements
- OAR 410-121-0032: Supplemental Rebate Agreements — authority
- OAR 410-121-0033: Polypharmacy Profiling — implements
- OAR 410-121-0060: How to Get Prior Authorization for Drugs — implements
- OAR 410-121-0061: Durable Medical Equipment, Medical Supplies, and Medical Surgical Services (Physician Administered Drugs) — implements
- OAR 410-121-0100: Drug Use Review — implements
- OAR 410-121-0111: Pharmacy and Therapeutics Committee — implements
- OAR 410-121-0135: Pharmacy Management Program — implements
- OAR 410-121-0143: Client Confidentiality — implements
- OAR 410-121-0145: Prescription Requirements — implements
- OAR 410-121-0146: Dispensing Limitations — implements
- OAR 410-121-0147: Exclusions and Limitations — implements
- OAR 410-121-0147: Exclusions and Limitations — authority
- OAR 410-121-0148: Dispensing in a Nursing Facility or Community Based Care Living Facility — implements
- OAR 410-121-0150: Billing Requirements — implements
- OAR 410-121-0155: Reimbursement — implements
- OAR 410-121-0157: Participation in the Medicaid Drug Rebate Program — implements
- OAR 410-121-0160: Dispensing Fees — implements
- OAR 410-121-0185: Pharmacy Based Immunization Delivery — implements
- OAR 410-121-0190: Medication Therapy Management Services and Clozapine Therapy Monitoring — implements
- OAR 410-121-0200: Billing Forms — implements
- OAR 410-121-0220: Instructions for Completion of the Prescription Drug Invoice — implements
- OAR 410-121-0280: Billing Quantities, Metric Quantities and Package Sizes — implements
- OAR 410-121-0300: CMS Federal Upper Limits for Drug Payments — implements
- OAR 410-121-0420: DESI Less-Than-Effective Drug List — implements
- OAR 410-121-0580: Oregon Medicaid and Pharmaceutical Manufacturers’ Dispute Resolution Procedures — implements
- OAR 410-121-0625: Items Covered in the All-Inclusive Rate for Nursing Facilities — implements
- OAR 410-122-0040: Prior Authorization — implements
- OAR 410-122-0040: Prior Authorization — authority
- OAR 410-122-0182: Legend — implements
- OAR 410-122-0186: Payment Methodology — implements
- OAR 410-122-0188: DMEPOS Rebate Agreements — implements
- OAR 410-122-0200: Pulse Oximeter for Home Use — implements
- OAR 410-122-0202: Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea — implements
- OAR 410-122-0202: Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea — authority
- OAR 410-122-0203: Oxygen and Oxygen Equipment — implements
- OAR 410-122-0204: Nebulizer — implements
- OAR 410-122-0205: Respiratory Assist Devices — implements
- OAR 410-122-0206: Intermittent Positive Pressure Breathing — implements
- OAR 410-122-0207: Respiratory Supplies — implements
- OAR 410-122-0208: Suction Pumps — implements
- OAR 410-122-0209: Tracheostomy Care Supplies — implements
- OAR 410-122-0210: Ventilators — implements
- OAR 410-122-0211: Cough Stimulating Device — implements
- OAR 410-122-0220: Pacemaker Monitor — implements
- OAR 410-122-0240: Apnea Monitors for Infants — implements
- OAR 410-122-0250: Breast Pumps — implements
- OAR 410-122-0260: Home Uterine Monitoring — implements
- OAR 410-122-0280: Heating/Cooling Accessories — implements
- OAR 410-122-0300: Light Therapy — implements
- OAR 410-122-0320: Manual Wheelchair Base — implements
- OAR 410-122-0325: Power Wheelchair Base — implements
- OAR 410-122-0330: Power-Operated Vehicle — implements
- OAR 410-122-0340: Wheelchair Options/Accessories — implements
- OAR 410-122-0360: Canes and Crutches — implements
- OAR 410-122-0365: Standing and Positioning Aids — implements
- OAR 410-122-0375: Walkers — implements
- OAR 410-122-0380: Hospital Beds — implements
- OAR 410-122-0400: Pressure Reducing Support Surfaces — implements
- OAR 410-122-0420: Hospital Bed Accessories — implements
- OAR 410-122-0475: Therapeutic Shoes for Diabetics — implements
- OAR 410-122-0510: Osteogenesis Stimulator — implements
- OAR 410-122-0515: Neuromuscular Electrical Stimulator (NMES) — implements
- OAR 410-122-0520: Glucose Monitors and Diabetic Supplies — implements
- OAR 410-122-0525: External Insulin Infusion Pump — implements
- OAR 410-122-0540: Ostomy Supplies — implements
- OAR 410-122-0560: Urological and Bowel Supplies — implements
- OAR 410-122-0580: Bath Supplies — implements
- OAR 410-122-0590: Patient Lifts — implements
- OAR 410-122-0600: Toilet Supplies — implements
- OAR 410-122-0620: Miscellaneous Supplies — implements
- OAR 410-122-0625: Surgical Dressing — implements
- OAR 410-122-0630: Incontinent Supplies — implements
- OAR 410-122-0630: Incontinent Supplies — authority
- OAR 410-122-0640: Eye Prostheses — implements
- OAR 410-122-0655: External Breast Prostheses — implements
- OAR 410-122-0658: Gradient Compression Stockings/Sleeves — implements
- OAR 410-122-0660: Orthotics and Prosthetics — implements
- OAR 410-122-0662: Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses — implements
- OAR 410-122-0678: Dynamic Adjustable Extension/Flexion Device — implements
- OAR 410-122-0680: Facial Prostheses — implements
- OAR 410-122-0700: Negative Pressure Wound Therapy Pumps — implements
- OAR 410-122-0710: Adaptive Car Seats and Travel Vests — implements
- OAR 410-122-0710: Adaptive Car Seats and Travel Vests — authority
- OAR 410-122-0720: Pediatric Wheelchairs — implements
- OAR 410-122-0730: Continuous Glucose Monitoring Equipment and Supplies — implements
- OAR 410-122-0730: Continuous Glucose Monitoring Equipment and Supplies — authority
- OAR 410-123-1060: Definitions and Acronyms — implements
- OAR 410-123-1060: Definitions and Acronyms — authority
- OAR 410-123-1160: Prior Authorization — implements
- OAR 410-123-1160: Prior Authorization — authority
- OAR 410-123-1250: HbA1c Testing — implements
- OAR 410-123-1260: Temporary rule language in effect until 09/22/2026. Coverage, Limitations, Exclusions — implements
- OAR 410-123-1260: Temporary rule language in effect until 09/22/2026. Coverage, Limitations, Exclusions — authority
- OAR 410-123-1262: Vaccine Counseling and Administration — implements
- OAR 410-123-1265: Teledentistry — implements
- OAR 410-123-1265: Teledentistry — authority
- OAR 410-123-1490: Hospital Dentistry — implements
- OAR 410-123-1490: Hospital Dentistry — authority
- OAR 410-123-1510: Additional Dental Benefits for Pregnant and Postpartum Members — implements
- OAR 410-123-1510: Additional Dental Benefits for Pregnant and Postpartum Members — authority
- OAR 410-123-1620: Coding and Documentation — implements
- OAR 410-124-0000: Transplant Services — implements
- OAR 410-124-0005: Donor Services — implements
- OAR 410-124-0006: Transplant Hospital Requirements And Reimbursement — implements
- OAR 410-124-0010: Eligibility for Transplant Services — implements
- OAR 410-124-0040: Emergency Transplants — implements
- OAR 410-125-0020: Retroactive Eligibility — implements
- OAR 410-125-0030: Hospital Hold — implements
- OAR 410-125-0040: Title XIX/Title XXI Clients — implements
- OAR 410-125-0041: Non-Title XIX/XXI Clients — implements
- OAR 410-125-0045: Temporary rule language in effect until 12/27/2026. Coverage and Limitations — implements
- OAR 410-125-0050: Client Copayments — implements
- OAR 410-125-0080: Inpatient Services — implements
- OAR 410-125-0085: Outpatient Services — implements
- OAR 410-125-0086: Prior Authorization for FCHP/MHO Clients — implements
- OAR 410-125-0090: Inpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals — implements
- OAR 410-125-0095: Hospitals Providing Specialized Inpatient Services — implements
- OAR 410-125-0101: Hospital-Based Nursing Facilities and Medicaid Swing Beds — implements
- OAR 410-125-0102: Medically Needy Clients — implements
- OAR 410-125-0103: Medicare Clients — implements
- OAR 410-125-0115: Non-Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003 — implements
- OAR 410-125-0120: Transportation To and From Medical Services — implements
- OAR 410-125-0121: Contiguous Area Out-of-State Hospitals — implements
- OAR 410-125-0124: Retroactive Authorization — implements
- OAR 410-125-0125: Free-Standing Inpatient Psychiatric Facilities — implements
- OAR 410-125-0140: Prior Authorization Does Not Guarantee Payment — implements
- OAR 410-125-0141: DRG Rate Methodology — implements
- OAR 410-125-0142: Graduate Medical Education Reimbursement for Public Teaching Hospitals — implements
- OAR 410-125-0150: Disproportionate Share — implements
- OAR 410-125-0155: Upper Limits on Payment of Hospital Claims — implements
- OAR 410-125-0162: Hospital Transformation Performance Program — implements
- OAR 410-125-0165: Transfers and Reimbursement — implements
- OAR 410-125-0170: Death Occurring on Day of Admission — implements
- OAR 410-125-0175: Hospitals Providing Specialized Outpatient Services — implements
- OAR 410-125-0180: Public Rates — implements
- OAR 410-125-0181: Non-Contiguous and Contiguous Area Out-of-State Hospitals — Outpatient Services — implements
- OAR 410-125-0190: Outpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals — implements
- OAR 410-125-0195: Outpatient Services In-State DRG Hospitals — implements
- OAR 410-125-0200: Time Limitation for Submission of Claims — implements
- OAR 410-125-0201: Independent ESRD Facilities — implements
- OAR 410-125-0210: Third Party Resources and Reimbursement — implements
- OAR 410-125-0220: Temporary rule language in effect until 12/27/2026. Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms — implements
- OAR 410-125-0221: Payment in Full — implements
- OAR 410-125-0360: Definitions and Billing Requirements — implements
- OAR 410-125-0400: Discharge — implements
- OAR 410-125-0401: Definitions: Emergent, Urgent, and Elective Admissions — implements
- OAR 410-125-0410: Readmission — implements
- OAR 410-125-0450: Provider Preventable Conditions — implements
- OAR 410-125-0550: X-Ray or EKG Procedures Furnished in Emergency Room — implements
- OAR 410-125-0600: Non-Contiguous Out-of-State Hospital Services — implements
- OAR 410-125-0620: Special Reports and Exams and Medical Records — implements
- OAR 410-125-0640: Third Party Payers — Other Resources, Client Responsibility and Liability — implements
- OAR 410-125-0641: Medicare — implements
- OAR 410-125-0720: Adjustment Requests — implements
- OAR 410-125-1020: Filing of Cost Statement — implements
- OAR 410-125-1040: Accounting and Record Keeping — implements
- OAR 410-125-1060: Fiscal Audits — implements
- OAR 410-125-1070: Type A and Type B Hospitals — implements
- OAR 410-125-1080: Documentation — implements
- OAR 410-125-2000: Access to Records — implements
- OAR 410-125-2020: Post Payment Review — implements
- OAR 410-125-2030: Recovery of Payments — implements
- OAR 410-125-2040: Provider Appeals — Administrative Review — implements
This rule cites
- ORS 414.690 — resolved
- 414.710 — resolved
- 414.712 — resolved
- 414.766 — resolved
- ORS 414.577 — resolved
Cited by
- ORS 413.614: COFA Dental Program established.
- ORS 413.650: Veterans Dental Program established; rules.
- ORS 414.025: Definitions for ORS chapters 411, 413 and 414.
- ORS 414.115: Medical assistance by insurance or service contracts; rules.
- ORS 414.135: Contracts relating to direct providers of care and services.
- ORS 414.225: Oregon Health Authority to consult with committee.
- ORS 414.668: Access to services provided by doulas, lactation counselors and lactation educators.
- ORS 414.761: Payment for bilateral cochlear implants, hearing aids and hearing assistive technology systems for minors.
- ORS 414.763: Payment for dispensing of 12-month supply of prescription contraceptives.
- ORS 414.764: Payment for services provided by pharmacy or pharmacist.
- ORS 414.766: Behavioral health treatment; rules.
- ORS 414.769: Payment for gender-affirming treatment; rules.
- ORS 414.770: Participants in clinical trials.
- ORS 414.775: Payment for COVID-19 testing and treatment.
- OAR 309-015-0000: Purpose and Statutory Authority
- OAR 309-048-0050: Statement of Purpose and Statutory Authority
- OAR 410-050-0700: Definitions
- OAR 410-120-0025: Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence
Official source: https://www.oregonlegislature.gov/bills_laws/ors/ors414.html