410-146-0020 Memorandum of Agreement Reimbursement Methodology (1) In 1996, a Memorandum of Agreement (MOA) between the Centers for Medicare and Medicaid Services (CMS) and the Indian Health Service (IHS) established the roles and responsibilities of CMS and IHS regarding the Division’s American Indian/Alaska Native (AI/AN) Program individuals. The MOA addresses payment for Medicaid services provided to AI/AN individuals on and after July 11, 1996, through health care facilities owned and operated by AI/AN tribes and tribal organizations, which are funded through Title I or V of the Indian Self-Determination and Education Assistance Act (Public Law 93-638). (2) The IHS and CMS, pursuant to an agreement with the Office of Management and Budget (OMB), developed an all-inclusive rate to be used for billing directly to and reimbursement by Medicaid. This rate is sometimes referred to as the "OMB," "IHS," "All-Inclusive" (AIR), "encounter," or "MOA" rate and is referenced throughout these rules as the "IHS rate." The IHS rate is updated and published in the Federal Register each fall: (a) The rate is retroactive to the first of the year; (b) The Division automatically processes a retroactive billing adjustment each year to ensure payment of the updated rate. (3) IHS direct health care service facilities established, operated, and funded by IHS shall enroll as an IHCP and receive the IHS rate. (4) Under the MOA, Tribal 638 health care facilities may choose to be designated a certain type of provider or facility for enrollment with OHP. The designation determines how the Division pays for the Medicaid services provided by that provider or facility. Under the MOA, a Tribal 638 health care facility may do one of the following: (a) Operate as a Tribal 638 health care facility. The health center would enroll as an IHCP and choose reimbursement for services at either: (A) The IHS rate; or (B) A cost-based rate according to the Prospective Payment System (PPS). Refer to OAR 410-147-0360, Encounter Rate Determinations, 410-147-0440, Medicare Economic Index (MEI), 410-147-0480, Cost Statement (OHP 3027) Instructions, and OAR 410-147-0500, Total Encounters for Cost Reports; or (b) If it so qualifies, operate as any other provider type recognized under the State Plan and receive that respective reimbursement methodology. (5) AI/AN and the Division’s FQHC and RHC program providers may be eligible to receive the supplemental/wraparound payment for services furnished to clients enrolled with a Prepaid Health Plan (PHP). Refer to AI/AN OAR 410-146-0420 and FQHC/ RHC administrative rules OAR chapter 410, division 147. (6) IHCPs may be eligible for an administrative match contract with the Division. IHCPs may not participate in the Medicaid Administrative Claiming (MAC) program if they: (a) Receive reimbursement for services according to the cost-based PPS rate methodology; or (b) Receive financial compensation for Out-Stationed Outreach Worker (OSOW) activities. (7) An IHCP that chooses to participate in the Patient Centered Primary Care Home program (PCPCH) must meet the requirements and adhere to rules outlined in OAR 409-055-0000 through 409-055-0080 Health Policy and Analytics and OAR 410-141-0860 Oregon Health Plan Primary Care Manager and Patient Centered Primary Care Home Provider Qualification and Enrollment. The PCPCH program is outside the Prospective Payment System and the IHS/MOA rate. IHCPs who choose to participate and meet all PCPCH related requirements shall receive a separate reimbursement per the per member per month (PMPM) payment established by OAR 410-141-0860. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017 DMAP 14-2012, f. & cert. ef. 3-22-12 DMAP 28-2011, f. 9-30-11, cert. ef. 10-1-11 DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08 OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04 OMAP 59-2002, f. & cert. ef. 10-1-02 OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01 OMAP 2-1999, f. & cert. ef. 2-1-99