Or. Admin. R. 410-151-0001

Current through Register Vol. 63, No. 8, August 1, 2024

Section 410-151-0001 - Definitions

The definitions in this rule apply to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program only.

(1) "EPSDT Dentally Appropriate"

(a) Means dental services, items, or dental supplies that are:

(A) Recommended by a licensed health practitioner practicing within the scope of their license; and

(B) Safe, effective, and appropriate for an EPSDT Beneficiary based on standards of good dental practice and generally recognized by the relevant scientific or professional community based on the best available evidence, which includes medical literature and expert consensus opinion and takes into account EPSDT Beneficiary values; and

(C) Impactful in improving access to care, ability to actively participate in care, work, school, or social activities; and not solely for the convenience or preference of an EPSDT Beneficiary, caregiver, or a provider of the service, item, or dental supply; and

(D) The most cost-effective level or type of health services, items, or supplies that are covered services that can be safely and effectively provided to an EPSDT Beneficiary.

(b) All covered services must be EPSDT Dentally Appropriate for the EPSDT Beneficiary but not all EPSDT Dentally Appropriate services are covered services.

(2) "EPSDT Beneficiary" means an individual under the age of 21 who is covered by the Oregon Health Plan (OHP).

(3) "EPSDT Medically Appropriate:"

(a) Means health services, items, or medical supplies that are:

(A) Recommended by a licensed health practitioner practicing within the scope of their license; and

(B) Safe, effective, and appropriate for the EPSDT Beneficiary and generally recognized by the relevant scientific or professional community based on the best available evidence, which includes medical literature and expert consensus opinion and takes into account EPSDT Beneficiary values; and

(C) Impactful in improving access to care, ability to actively participate in care, work, school, or social activities and not solely for the convenience or preference of an EPSDT Beneficiary, caregiver, or a provider of the service, item, or medical supply; and

(D) The most cost-effective level or type of health services, items, or medical supplies that are covered services that can be safely and effectively provided to an EPSDT Beneficiary.

(b) All covered services must be EPSDT Medically Appropriate for the EPSDT Beneficiary, but not all EPSDT Medically Appropriate services are covered services.

(4) "EPSDT Medically Necessary:"

(a) Means health services, items and medical supplies that are required to address one or more of the following for an EPSDT Beneficiary:

(A) The prevention, diagnosis, treatment or amelioration of an EPSDT Beneficiary's disease, condition, or disorder that results in health impairments or a disability;

(B) The ability for an EPSDT Beneficiary to achieve age-appropriate growth and development. Services that may be EPSDT Medically Necessary to achieve age-appropriate growth and development include but may not be limited to services that are reasonably calculated to improve the EPSDT Beneficiary's ability to participate in work or school, or the prevention, diagnosis, detection, treatment, cure, correction, reduction, or alleviation of the effects of a physical, mental, behavioral, nutritional, dental, genetic, developmental or congenital condition, injury, or disability, regardless of whether they are included on the Prioritized List of Health Services (defined in OAR 410-120-0000) or are below the funding line on the Prioritized List of Health Services;

(C) The ability for an EPSDT Beneficiary to attain, maintain, or regain independence in self-care, ability to perform activities of daily living or improve health status; or

(D) The opportunity for an EPSDT Beneficiary receiving Long Term Services & Supports (LTSS) to have access to the benefits of non-institutionalized community living, to achieve person-centered care goals, to participate in their own care planning, and to live and work in the setting of their choice.

(b) An EPSDT Medically Necessary service must also be EPSDT Medically Appropriate. All covered services must be EPSDT Medically Necessary for the EPSDT Beneficiary.

Or. Admin. R. 410-151-0001

DMAP 97-2023, adopt filed 12/27/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150