Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1295 - Non-Participating Provider

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes
			 of this rule, a provider enrolled with the Health Systems Division (Division)
			 that does not have a contract with a Division-contracted Managed Care Entity
			 (MCE) is referred to as a non-participating provider.
(2) For services covered by the CCO or PHP, a
			 non-participating provider, other than a hospital governed by (3) of this rule,
			 must accept from the Division-contracted MCE, as payment in full, the amount
			 that the provider would be paid from the Division if the client was
			 fee-for-service (FFS).
(3) For
			 covered services provided on and after October 1, 2011, the Division-contracted
			 MCE that does not have a contract with a hospital, is required to reimburse,
			 and hospitals are required to accept as payment in full, the following
			 reimbursement:
(a) Non-participating Type A
			 and Type B hospital: The MCE shall reimburse a non-participating Type A and
			 Type B hospital fully for the cost of covered services based on the
			 cost-to-charge ratio used for each hospital in setting the global payments to
			 the MCE for the contract period;
(b) Hospitals (not designated as a rural
			 access or Type A and Type B hospital) including Child/Adolescent Psychiatric
			 units in a hospital: As specified in ORS
			 414.743, the MCE shall reimburse
			 inpatient and outpatient services using a Medicare payment methodology at a
			 specified percentage point less than the percentage of Medicare costs used by
			 the Oregon Health Authority (Authority) when calculating the base hospital
			 capitation payment to the MCE excluding any supplemental payments.
(A) Effective for services on or after
			 October 1, 2011, for a hospital providing 10 percent or more of the hospital
			 admissions and outpatient hospital services to enrollees of the plan, the
			 percentage of the Medicare reimbursement shall be equal to 64
			 percent;
(B) Effective for services
			 on or after October 1, 2011, for a hospital providing less than 10 percent of
			 the hospital admissions and outpatient hospital services to enrollees of the
			 plan, the percentage of the Medicare reimbursement shall be equal to 66
			 percent.
(C) Effective for services
			 on or after January 1, 2020 for a hospital providing 10 percent or more of the
			 hospital admissions and outpatient hospital services to enrollees of the plan,
			 the percentage of the Medicare reimbursement shall be equal to 76
			 percent.
(D) Effective for services
			 on or after January 1, 2020 for a hospital providing less than 10 percent of
			 the hospital admissions and outpatient hospital services to enrollees of the
			 plan, the percentage of the Medicare reimbursement shall be equal to 78
			 percent.
(E) Effective for services
			 on or after January 1, 2023 but before January 1, 2024,
(i) For a hospital providing 10 percent or
			 more of the hospital admissions and outpatient hospital services to enrollees
			 of the plan, the percentage of the Medicare reimbursement shall be equal to 81
			 percent; and
(ii) For a hospital
			 providing less than 10 percent of the hospital admissions and outpatient
			 hospital services to enrollees of the plan, the percentage of the Medicare
			 reimbursement shall be equal to 83 percent.