Oregon Administrative Rules › Chapter 309 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: BEHAVIORAL HEALTH SERVICES › Division 15 - MEDICAID PAYMENT FOR PSYCHIATRIC HOSPITAL INPATIENT SERVICES › Section 309-015-0025 - Retrospective Settlement Rate Setting (Year End and Final)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Year-end settlement process. The year-end
			 settlement process will be as follows:
(a)
			 Upon receipt of an audited Medicaid cost report from the Supervisor of the
			 Division Audit Section, the Revenue and Rates Manager of the Institutional
			 Revenue Section will determine a retrospective year-end settlement rate for
			 each participating hospital, separate cost entity or distinct program within a
			 hospital on the basis of Division review of actual allowable Medicaid costs
			 reported in the hospital's cost statement for the previous year;
(b) The year-end settlement rate for a
			 non-disproportionate share hospital will be calculated by using the following
			 procedure:
(A) Divide the applicable Title XIX
			 allowable costs for each participating hospital, separate cost entity, or
			 distinct program by the applicable number of Title XIX patient days, including
			 therapeutic leave days;
(B) If the
			 hospital has more than one distinct program, divide the applicable Medicaid
			 allowable costs by the applicable number of Medicaid patient days, including
			 therapeutic leave days for each program. Then determine the weighted average
			 Medicaid settlement rate for the entire hospital. This is accomplished by
			 multiplying each proposed year-end settlement rate by Medicaid patient days for
			 that rate, adding the products together, and dividing the resulting sum by
			 total Medicaid patient days for the hospital;
(C) If the year-end Medicaid settlement rate
			 or the average year-end Medicaid settlement rate from above is less than the
			 maximum allowable Medicaid rate for psychiatric hospitals during the current
			 fiscal year, use the lower rate;
(D) If the year-end Medicaid settlement rate
			 or the average year-end settlement rate from above exceeds the maximum
			 allowable rate established for psychiatric hospitals during the current fiscal
			 year, use the maximum allowable rate as the retrospective year-end settlement
			 rate for the hospital.
(c) The year-end settlement rate may exceed
			 the maximum allowable rate if the Division determines the hospital meets the
			 criteria listed in OAR
			 309-015-0035(5)
			 as a disproportionate share hospital;
(d) In that case, the disproportionate share
			 adjusted year-end settlement rate will be calculated as follows:
(A) Actual costs up to 135 percent of the
			 maximum allowable rate; or
(B)
			 Actual costs up to 100 percent of the cost of uncompensated care during the
			 facility's previous fiscal year, subject to a disproportionate share allotment
			 established yearly by the Health Care Financing Administration, if the
			 psychiatric hospital has a low-income rate of 60 percent and also receives 60
			 percent or more of its service revenue from any combination of the following:
(i) Public funds, excluding Medicare and
			 Medicaid;
(ii) Bad debts;
			 or
(iii) Free
			 care.
(e) The
			 year-end settlement will be determined by multiplying the settlement "rate"
			 calculated above by the total number of Medicaid patient days, including
			 therapeutic leave days or, for disproportionate share hospitals, multiplying
			 the disproportionate share adjusted rate by the total number of Medicaid
			 patient days, including therapeutic leave days. The result will be compared to
			 the amount of reimbursement paid to the hospital during the fiscal period. If
			 the result favors the hospital, the Division will pay the difference to the
			 hospital. If the result favors the Division, the hospital will pay the
			 difference to the Division. In either case, payments shall be made within 30
			 days approval of the year-end Medicaid cost report by the Medicaid
			 Intermediary.