Oregon DFR Bulletin 2023-4: Reimbursement of Nurse Home Visiting Services

350 Winter St. NE, Rm 410, PO Box 14480, Salem, OR 97309 503-947-7694 dfr.oregon.gov 1 Oregon Department of Consumer and Business Services Division of Financial Regulation, Bulletin No. DFR 2023-4 To: All entities offering health benefit plans Date: October 12, 2023 RE: Reimbursement of Nurse Home Visiting Services Purpose The purpose of this bulletin is to:

1. Establish the director’s expectations for health benefit plan issuers on how to reimburse providers of the Family Connects service.
2. Establish the director’s expectations for treatment of claims for Family Connects services by high deductible health plans. Authority ORS 742.008, ORS 743A.078 Background In 2019, the Oregon legislature enacted Senate Bill 526, establishing the universally offered newborn nurse home visiting program “Family Connects Oregon.” Health benefit plans are required to cover the full cost of nurse home visiting services provided through this program at no cost to the consumer, with no deductible, co-pays, or co-insurance applied. In 2022, the Oregon legislature passed Senate Bill 1555, directing the Oregon Health Authority (OHA) to establish by rule a methodology for calculating the “full cost” of nurse home visiting services provided through the program. On October 29, 2022, OHA finalized rules defining the methodology for calculating the required reimbursement rate for nurse home visiting services provided through the program. These are codified at OAR 333-006-0180 and OAR 333-006-0190. On October 14, 2022, OHA released guidance on how the nurse home visiting services are to be coded in a document titled “Family Connects Oregon Coding Guidance for Commercial Health Benefit Plan Claims” (the “OHA Coding Guidance”), and the reimbursement rate that must be paid for said services in a document titled “Family Connects Oregon Rate Announcement” (the “OHA Rate Announcement”). These documents are retrievable via links on the webpage accessible at: https://www.oregon.gov/oha/PH/HEALTHYPEOPLEFAMILIES/BABIES/HOMEVISITING/Pages/ FCO-Information-for-Commercial-Insurance-Carriers.aspx Under federal law, a consumer may contribute to a tax advantaged Health Savings Account only if they are enrolled in a High Deductible Health Plan (HDHP) as described in Title 26 USC §
3. A HDHP may not cover any of the cost of medical services ahead of a member’s

2 deductible, except to the extent that they qualify as “preventive care” under the federal Patient Protection and Affordable Care Act (ACA). Under current federal guidance, Family Connects services do not qualify as preventive care under the ACA. ORS 742.008 permits the Department of Consumer and Business Services (DCBS) to accept health benefit filings that are non-compliant with Oregon law, if that non￾compliance is solely due to application of a deductible to services not considered preventive care under the ACA. Expectations for Health Benefit Plan Issuers

1. General Expectations A carrier offering a health benefit plan other than a HDHP will be considered in compliance with the requirement to reimburse the cost of a universally offered home visit under ORS 743A.078 if, upon receiving a procedure claim coded as a Family Connects visit, as specified in the OHA Coding Guidance (99502 32; 99502 32 TD; or 99502 32 TT), they reimburse the billing provider in the following amounts: • For claims coded 99502 32, the statewide “Case rate” defined in the applicable OHA Rate Announcement. • For claims coded 99502 32 TD, the “Single support visit rate” defined in the applicable OHA Rate Announcement. • For claims coded 99502 32 TT, the “Multiple newborn rate” defined in the applicable OHA Rate Announcement. The OHA Rate Announcement will be updated periodically, with the new document superseding rates in the prior announcement for claims occurring after the new announcement’s effective date. Current and previously issued rate guidance will be retrievable via links on the previously referenced webpage accessible at: https://www.oregon.gov/oha/PH/HEALTHYPEOPLEFAMILIES/BABIES/HOMEVISITING/Pages/ FCO-Information-for-Commercial-Insurance-Carriers.aspx For any given Family Connects visit, carriers should refer to the OHA Rate Announcement that covers the date range within which the visit occurred to determine the applicable case rate. The date range for each announcement will be identified in both the link on the webpage and in the body text of the document.
2. Expectations for High Deductible Health Plans A carrier offering a health benefit plan that is also an HDHP is not required to reimburse a provider for any portion of the cost of a Family Connects visit for an enrollee who has not met their deductible as of the date of visit. If an enrollee has already met their deductible an issuer of a HDHP will be considered in compliance with ORS 743A.078 if they reimburse the Family Connects provider at the rates described above in the applicable OHA Rate Announcement. Pursuant to ORS 742.008, DCBS will not disapprove a plan that is offered as an HDHP solely on the basis that the plan does not cover Family Connects services ahead of deductible.

3 10/12/2023 This bulletin is effective upon issuance.

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Andrew R. Stolfi Date Insurance Commissioner and Director Department of Consumer and Business Services