1. (1) The Healthier Oregon medical assistance benefit package is equal to the medical assistance benefits package defined and describe in OAR 410-120-1210 as OHP Plus but the funding for the benefits is different as set out in this rule.

2. (2) Emergency Health Benefit Funding includes services that are funded in part with state dollars and matched with federal dollars. Emergency Health Benefit Funding includes:

   1. (a) Services to treat Emergency Medical Conditions as defined by 42 CFR 440.255 and OAR 410-120-0000. The Healthier Oregon Desk Reference, defines claims and limitations for services listed below, that the Oregon Health Authority determines an emergency located at: https://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-CWM.aspx ;
   2. (b) Labor and Delivery;
   3. (c) Behavioral Health Crisis as defined in OAR 309-019-0105;
   4. (d) Outpatient dialysis to treat acute renal failure or End Stage Renal Disease (ESRD);
   5. (e) Immunosuppressant medications post kidney transplant, including office visits and labs to prescribe and monitor such medications;
   6. (f) Cancer treatment;
   7. (g) Dental services provided in an emergency department or hospital setting;
   8. (h) Covid 19 coverage shall be equal to the coverage available during the Federal Public Health Emergency (PHE) and shall end May 11, 2024;
   9. (i) Pregnancy coverage equal to OHP Plus defined in OAR 410-120-1210; subparagraphs (3)(a-m) of this rule are funded by Supplemental Health Benefits State Funding. Pregnancy coverage is partially funded through Children Health Insurance Program (CHIP) as defined in 42 CFR §§ 457.10 and 457.618;
   10. (j) Post-Partum coverage equal to OHP Plus defined in OAR 410-120-1210; subparagraphs (3)(a-m) of this rule set are funded by Supplemental Health Benefits State Funding, beginning the day after pregnancy ends and ending (12) twelve calendar months following the month in which the pregnancy ends. Post-partum coverage is partially funded through CHIP administrative funds as available and reverts to Supplemental Health Benefits State Funding, when CHIP administrative funds are not as available.

3. (3)  Supplemental Health Benefit State Funding includes services that are funded with state funds only. State-Funded Supplemental Health Benefits include:

   1. (a) Abortion services;
   2. (b) Sterilization;
   3. (c) Family Planning;
   4. (d) Hospice;
   5. (e) Death with dignity;
   6. (f) Dental services equal to OHP coverage in OAR 410-123-1220;
   7. (g) Post-Partum coverage beginning the day after pregnancy ends and ending (12) twelve calendar months following the month in which the pregnancy ends; if CHIP administrative funds are not available;
   8. (h) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage and limitations defined in OAR 410-151-0000;
   9. (i) Organ Transplants see OAR 410-124-0010;
   10. (j) Pharmacy benefits equal to OHP Plus coverage;

   11. (k) Long-Term Support Services (LTSS) defined in OAR 410-120-0000;

       1. (L) Health Related Social Needs (HRSN) defined in OAR 410-120-0000
   12. (m) OHP Plus coverage and limitations described in OAR 410-120-1210.

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 413.042, 414.065, ORS 414.231, 414.312, 414.430, 414.432 & 414.706

History

DMAP 66-2025, minor correction filed 09/09/2025, effective 09/09/2025
DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023
DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023
DMAP 13-2023, minor correction filed 03/30/2023, effective 03/30/2023
DMAP 94-2022, amend filed 12/27/2022, effective 01/01/2023
DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022