|Are mental health care and chemical dependency services a part of the Prioritized List?|
Mental health care
and chemical dependency lines are fully integrated and prioritized along with
physical conditions. Mental health lines are distinguished by the listing
of "psychotherapy" under the treatment description. The listing
of psychotherapy represents a broad range of mental health therapies provided
by different types of mental health professionals in various settings.
|Are prescription drugs covered for all diagnoses?|
The Commission considers prescription drugs to be an ancillary service. Therefore, it is the intent of the HERC that only funded condition-treatment pairs include the coverage of prescription drugs. However, the Commission has discovered that since the diagnosis is not included with a prescription, the pharmacy has no way to determine if a drug is being prescribed for a condition falling below the funding line. Within the past few years, prescribing physicians have been asked to check a box to indicate whether or not the prescription is for the treatment of a covered condition.
|Does the line descriptor contain every diagnosis?|
Each line has a description of both a condition and treatment. For some lines there is only one condition, but for others there may be many. The line descriptor contains the most frequent condition or a cluster of conditions represented by the ICD-10-CM codes. For example, cystic
fibrosis occurs by itself on line 24, but the codes on line 210, described broadly as Zoonotic Bacterial Diseases, include plague, tularemia, anthrax, brucellosis, catscratch disease and other specific diseases.
|How is the funding line established?|
Oregon Legislative Assembly will review the Prioritized List included in this
report. If this report is accepted, they will establish a funding line
for this list in accordance with the state budget. Upon approval from the
Centers for Medicare and Medicaid Services (CMS), the benefit package
represented by the services listed on or above that funding line will be
reimbursed under the Medicaid Demonstration beginning no earlier than October
|What about diagnostic services?|
Except for rare
instances, diagnostic services are always covered and do not appear on the
list. If a condition is diagnosed that appears below the funding line,
the diagnostic visit and any necessary tests will be covered, but subsequent
office visits and ancillary services such as home health services will not.
|What about preventive services?|
The Oregon Health Plan encourages prevention and early intervention. Effective preventive services for adults and children are ranked on Line 3 and include services recommended by the U.S. Preventive
Services Task Force (“A” and “B” Recommendations), American Academy of Pediatrics (Bright Futures Guidelines), Health Resources and Services Administration (Women’s Preventive Services) and the Advisory Committee on C-4 Immunization Practives (as approved for the Oregon Immunization Program). In addition, preventive dental services are included on Line 57.
|What are ancillary services and are they covered?|
services are those goods, services, and therapies that are considered to be
integral to the successful treatment of a condition. Ancillary services
are reimbursable when used in conjunction with a covered condition.
|What are practice guidelines?|
Guidelines are used
to further delineate conditions where the coding system does not adequately
distinguish between sub-groups that are treated differently or to indicate the
most effective use of a particular treatment. See Chapter Two of the Biennial Report for further
detail on new guidelines developed and existing guidelines that were modified
over the last two years. A listing of the guideline titles is provided at
the end of this appendix. This includes guidelines associated with
diagnostic and ancillary services that don’t appear on the Prioritized List as
well as services that do appear on the list. A full listing of the
practice guidelines are posted on the Commission’s website.
|What are statements of intent? |
Statements of intent
allow the Commission the ability to indicate their intent for coverage of services
that cannot be easily identified by medical codes. These statements
appear later in this appendix immediately following the Prioritized List.
|What do the line numbers represent?|
The line numbers represent the rank order of the condition-treatment pairs assigned by the Health Evidence Review Commission. Therefore the services on line item 1 are most important to provide and line item 669 the least important in terms of the benefit to be gained by the
population being served.
|What other resources are available to answer other questions I may have? |
|Why do many diagnoses appear more than once?|
A given diagnosis or
condition may have a continuum of treatments including medical, surgical, or
transplantation. All transplantations for either bone marrow or solid
organs have a separate line in addition to the medical/surgical treatment.
These treatments of a condition may vary in their effectiveness and/or cost and
therefore receive different rankings by the Health Evidence Review Commission.