Oregon Administrative Rules › Chapter 309 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: BEHAVIORAL HEALTH SERVICES › Division 15 - MEDICAID PAYMENT FOR PSYCHIATRIC HOSPITAL INPATIENT SERVICES › Section 309-015-0035 - Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Timing.
			 Payments to providers will be made following the month of service, based on the
			 invoice submitted by the provider to the Division of Medical Assistance
			 Programs.
(2) Eligible services.
			 Payments will be made for the provision of active psychiatric inpatient
			 treatment services for persons eligible for such services under
			 Medicaid.
(3) Non-eligible
			 services. If review of a psychiatric hospital's Medicaid patient records by a
			 Professional Standards Review Organization reveals that a patient received an
			 inappropriate level of care, (i.e., less than active treatment), payment will
			 not be allowed under these rules. Any payments to the provider for patients
			 receiving an inappropriate level of care shall be recovered by the Division.
			 Such payments shall be reported to the Division of Medical Assistance Programs
			 on an adjustment form specified by the Division of Medical Assistance Programs.
			 Failure to report such payments will be considered concealment of material
			 facts and is grounds for sanction (see OAR
			 309-015-0052).
(4) Payment to non-disproportionate share
			 hospitals. The Division shall not pay more in total for psychiatric hospital
			 inpatient services for hospitals which do not serve a disproportionate number
			 of low-income patients with special needs than would be paid under the Medicare
			 principles of reimbursement.
(5)
			 Payment to disproportionate share hospitals. A participating psychiatric
			 hospital may be reimbursed for allowable costs in excess of the maximum rate if
			 it meets the following criteria as described in Section 1923(b)(3) of the
			 Social Security Act: The hospital serves disproportionate numbers of low-income
			 persons; i.e., has a low income utilization rate which exceeds 25 percent using
			 the following formula:
(a) The total Medicaid
			 in-patient revenues paid to the hospital, plus the amount of the cash subsidies
			 received as payment for inpatient services directly from state and local
			 governments in a cost reporting period, divided by the total amount of revenues
			 of the hospital for in-patient psychiatric services (including the amount of
			 such cash subsidies) in the same cost reporting period. The percentage derived
			 in paragraph (a) of this subsection shall be added to the following
			 percentage;
(b) The total amount of
			 the hospital's charges for in-patient psychiatric services attributable to
			 charity care (care provided to individuals who have no source of payment,
			 third-party or personal resources) in a cost reporting period, less the portion
			 of any cash subsidies for in-patient services received directly from state and
			 local governments described in paragraph (A) of this subsection in the period
			 attributable to in-patient hospital services, divided by the total amount of
			 the hospital's charges for in-patient psychiatric services in the hospital in
			 the same period. The total in-patient charges attributed to charity care shall
			 not include contractual allowances and discounts (other than for indigent
			 patients not eligible for Medical Assistance under an approved Medicaid State
			 Plan);
(c) The sum of percentages
			 derived in paragraphs (a) and (b) of this subsection shall exceed 25 percent in
			 order to qualify as a disproportionate share hospital; and
(d) The hospital is efficiently and
			 economically operated and is in compliance with treatment and program standards
			 for psychiatric inpatient services as required by the state and federal
			 statutes and regulations.