Medicaid Benefits: Online Database

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Acute Care Services

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Products and Devices

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Oregon (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes	A - $3/visit	Specified surgical procedures	Specified procedures require a second opinion	Fee for service, second and subsequent surgeries performed at same time paid a lesser rate	A - See state-specific FN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	A - $3/visit	Specified procedures		Fee for service	A & B - See state-specific FN
Federally Qualified Health Center Services
Yes	A - $3/visit			Prospective cost based rate/visit	A & B - See state-specific FN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	A - $3/admission	Non-emergency transfers, readmissions for specified services	A & B - specified procedures require a second opinion, B - limited to admissions for urgent or emergency medical care only	Prospective payment/discharge using DRG, cost based payment for small hospitals	A & B - See state-specific FN
Outpatient Hospital Services
Yes	A - $3/visit	Specified surgical and therapy procedures		Cost based payment with limits	A & B - See state-specific FN
Rehabilitation Services: Mental Health and Substance Abuse
Yes	A - $3/visit	Specified procedures		Fee for service or negotiated rate	A & B - See state-specific FN
Rural Health Clinic Services
Yes	A - $3/visit			Prospective cost based rate/visit	A & B - See state-specific FN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service	A & B - See state-specific FN
Chiropractor Services
Yes	A - $3/visit			Fee for service	A - See state-specific FN
Dental Services
Yes	A - $3/visit except diagnostic tests and routine exam/cleaning		B - limited to emergency treatment for pain and infection	Fee for service	A & B - See state-specific FN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes	A - $3/visit	Specified services	A - specified procedures require a second opinion, B - limited to emergency treatment for pain and infection	Fee for service	A & B - See state-specific FNN
Nurse Midwife Services
Yes	A - $3/visit			Fee for service	A & B - See state-specific FN
Nurse Practitioner Services
Yes	A - $3/visit			Fee for service	A & B - See state-specific FN
Optometrist Services
Yes	A - $3/visit		1 refractive exam/2 years	Fee for service	A - See state-specific FN
Physician Services
Yes	A - $3/visit	Specified surgical and therapy procedures	A & B - specified procedures require a second opinion, B - osteopathic manipulative therapy not covered	Fee for service, second and subsequent surgeries performed at same time paid a reduced fee	A & B - See state-specific FN
Podiatrist Services
Yes	A - $3/visit	Specified services and appliances	Second opinion required for specified services, routine foot care not covered	Fee for service, second and subsequent surgical procedures same session paid 50% of fee or less, drugs, supplies and appliances paid cost	A - See state-specific FN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes	A - $1/non-preferred PDL generic or generic in non-PDL class costing more than $10; $3/brand Rx	Specified drugs including nutritional supplements, growth hormones and anti-ulcer drugs		AWP-15%, plus $3.50 dispensing fee for traditional pharmacies, AWP-11%, plus $3.91 dispensing fee for non-traditional pharmacies	A & B - See state-specific FN
Physical Therapy and Other Services
Occupational Therapy Services
Yes	A - $3/visit	Yes		Fee for service	A - See state-specific FN
Physical Therapy Services
Yes	A - $3/visit	Yes		Fee for service	A - See state-specific FN
Services for Speech, Hearing and Language Disorders
Yes	A - $3/visit	Yes		Fee for service	A - See state-specific FN
Products and Devices
Dentures
Yes				Fee for service	A - See state-specific FN
Eyeglasses
Yes		Items from other than state's contractor	1 pair eyeglasses/2 years; contact lenses if specified criteria met; multiple pairs, special lenses and low vision aids not covered	Most products provided by state's volume purchase contractor, dispensing provider paid fee for service, acquisition cost for other items	A - See state-specific FN
Hearing Aids
Yes		Specified items		Fee for service	A - See state-specific FN
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items	B - limited to specified diabetic, ostomy and respiratory med equipment and supplies	Fee for service	A & B - See state-specific FN
Prosthetic and Orthotic Devices
Yes		Specified services or items		Fee for service	A - See state-specific FN
Transportation Services
Ambulance Services
Yes				Fee for service	A & B - See state-specific FN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	A - See state-specific FN
Other Services
Diagnostic, Screening and Preventive Services
Yes				Fee for service	A & B - See state-specific FN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes		Specified services		Fee for service	A & B - See state-specific FN
Targeted Case Management
Yes				Fee for service or cost based payment	A - See state-specific FN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes			Services for the following populations: 2, 4, 6 & 8 - See service-specific FN	Dependent upon the services provided	A & B - See state-specific FN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	A - $3/visit	Med equipment and supplies over specified cost thresholds		Fee for service	A - See state-specific FN
Hospice Care
Yes				Prospective rates based on Medicare methodology	A & B - See state-specific FN
Personal Care Services
Yes		Yes		Established hourly rate for individual providers and negotiated rate for agencies	A - See state-specific FN
Private Duty Nursing Services
Yes		Yes		Fee for service	A - See state-specific FN
Program of All-Inclusive Care for the Elderly
Yes			See service-specific FN	Capitated payment	A & B - See state-specific FN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes			Leave days not covered	Prospective cost based per diem	A - See state-specific FN
Inpatient Psychiatric Services, under age 21
Yes				Prospective cost based per diem	A - See state-specific FN
Intermediate Care Facility Services for the Mentally Retarded
Yes			14 leave days/month of any type	Cost based payment	A - See state-specific FN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes			Leave days not covered	Prospective per diem based on cost	A - See state-specific FN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 Waiver from CMS under which it implemented a prioritized list of covered health services for its Medicaid program, called the Oregon Health Plan (OHP), based on their comparative benefit to the population served. Through an amendment to the waiver implemented in 2003 the State extended Medicaid eligibility to a number of previously uninsured individuals. The traditional Medicaid population, covered under OHP Plus and identified as “A” on the tables for 2004 and 2006, includes families with income below the federal poverty level (FPL), the elderly, blind and disabled, and pregnant women and children living in families with income at or below 185 percent of the FPL. Also covered under OHP Plus is the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA), some of whom are required to pay a monthly premium. The waiver’s expansion population, covered under OHP Standard and identified as “B” on the tables for 2004 and 2006, includes adults with income below the FPL not eligible for traditional Medicaid coverage. The benefit package for the OHP Standard program is more limited than for the OHP Plus program. OHP Standard participants who become pregnant are transferred to the OHP Plus program for the duration of their pregnancy and two months post partum. OHP Plus program participants age 19 and older are required to make copayments for specified services if the program makes any payment, even if Medicare or their private insurance covered part of the cost of the service. Imposition of a copayment requirement on the OHP Standard group has been prohibited as the result of a court order, but this population is required to pay income-based monthly premiums based on income above 10 percent of the FPL.