Oregon

- In 2011 became the third state to pass DPC legislation.  For the text of the law, see ORS § 735.500 and ORS § 735.510.  We recommend reviewing ORS Title 56 Insurance to better understand the "business of insurance" hurdles that must be avoided; note that Oregon requires registration to perform in-office dispensing with the state medical board.  For DPC practices contemplating adding a physician assistant, note that a different set of rules apply for in-office dispensing by a PA.  

- Oregon's Dept of Consumer & Business Services has a homepage for their retainer law, but has also published several documents that physicians contemplating a DPC practice will want to reference:

The Oregon DPC law is easily the worst of all states.  DPC physicians will be disappointed in many ways:

  • The law fails to explicitly state that DPC is "not insurance"
  • The Oregon Dept of Insurance was granted
    • the ability to investigate and subpoena DPC practices
    • broad authority to adopt new rules
  • A separate license and registration is needed to operate a DPC practice
  • The law fails to distinguish DPC and Concierge practices (as evidenced by this registered list of practices - click the link and then filter by "retainer" practices to see the listing)

Oregon's Medicaid Provider Manual (page 42) references Oregon Administrative Rule 410-120-1280 when contemplating ways that physicians may privately charge Medicaid patients.  The provider manual states that "Generally, a provider may legally bill an OHP recipient in the following two circumstances: (refer to above OAR for other examples) 1. The service provided is not covered by the OHP and the member signed an OHP Client Agreement to Pay for Health Services form before the member was seen. This form can be found at the following link:  The form must include the specific service that is not covered under the OHP, the date of the service and the approximate cost of the service. The estimated cost of the covered service, including all related charges, cannot exceed the maximum DMAP reimbursable rate or managed care plan rate. The form must be written in the primary language of the member. 2. The member did not tell the provider that he/she had Medicaid insurance and the provider tried to obtain insurance information. 

Part 3(g) of Administrative Rule 410-120-1280 states how a Medicaid recipient may be billed for covered services:

(g) In exceptional circumstances, a client may decide to privately pay for a covered service. In this situation, the provider may bill the client if the provider informs the client in advance of all of the following:

(A) The requested service is a covered service, and the appropriate payer (the Division, MCE, or third party payer) would pay the provider in full for the covered service; and

(B) The estimated cost of the covered service, including all related charges, the amount that the appropriate payer would pay for the service, and that the provider cannot bill the client for an amount greater than the amount the appropriate payer would pay; and

(C) That the client knowingly and voluntarily agrees to pay for the covered service;

(D) The provider documents in writing, signed by the client or the client's representative, indicating that the provider gave the client the information described in section (3)(g)(A-C); that the client had an opportunity to ask questions, obtain additional information, and consult with the client's caseworker or client representative; and that the client agreed to privately pay for the service by signing an agreement incorporating all of the information described above. The provider must give a copy of the signed agreement to the client. A provider may not submit a claim for payment for covered services to the Division or to the client's MCE or third party payer that is subject to the agreement.

Part 3(h) of Administrative Rule 410-120-1280 states how a Medicaid recipient may be billed for Non-covered services:

(h) A provider may bill a client for services that are not covered by the Division, MCE (see definition of non-covered services). Before providing the non-covered service, the client must sign the provider-completed Agreement to Pay (OHP 3165) or a facsimile containing all of the information and elements of the OHP 3165 as shown in Table 3165 of this rule. The completed OHP 3165 or facsimile is valid only if the estimated fee does not change and the service is scheduled within 30 days of the client’s signature. Providers must make a copy of the completed OHP 3165 or facsimile available to the Division or MCE upon request.