Oregon State Archives

Oregon Bulletin

December 1, 2011

Oregon Health Authority,
Division of Medical Assistance Programs
Chapter 410

Rule Caption: July 2011 — update criteria for definitions, exceptional needs, client materials and payment.

Adm. Order No.: DMAP 29-2011

Filed with Sec. of State: 10-19-2011

Certified to be Effective: 10-20-11

Notice Publication Date: 5-1-2011

Rules Amended: 410-141-0300, 410-141-0420

Rules Repealed: 410-141-0110, 410-141-0115

Subject: The Oregon Health Plan (Managed Care) program administrative rules govern Division payments for services to clients. The Division will amend as follows:

      • OAR 410-141-0300 to update client materials requirements and OHA stat line.

      • OAR 410-141-0420 to update provider enrollment criteria and OHA stat line.

      The Division will repeal as follows:

      • OAR 410-141-0110 to remove PHP survey criteria; obsolete.

      • OAR 410-141-0115 to remove PCM survey criteria; obsolete.

      All Division rules reflect the name change from the Department of Human Services to the Oregon Health Authority. Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

      Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-141-0300

Managed Care Prepaid Health Plan Member Education Requirements

A Managed Care Organization (MCO) plan member, also known as Division member (member), pertains to Division of Medical Assistance Programs’ (Division) clients enrolled in a Managed Care Organization (MCO).

(1) MCOs shall have written procedures, criteria and an ongoing process of member education and information sharing that include orientation to the MCO, a member handbook and health education.

(2) MCOs shall mail a new member packet to new members, and to members returning to the plan 9 months or more after previous enrollment, within 14 calendar days of the date the plan receives notice of the member’s enrollment, including at a minimum a member handbook, provider directory and welcome letter.

(3) MCO member handbook:

(a) For members who are ongoing enrollees, the MCO member handbook and provider directory shall be offered annually and sent on request. Whenever they are offered they shall be offered in print, and may also be offered online if available;

(b) Each version of the printed MCO member handbook and provider directory shall be submitted electronically to the Division of Medical Assistance Programs’ (Division) Materials Coordinator and Addictions and Mental Health (AMH) Division Representative for approval. At a minimum the MCO member handbook shall contain the following elements:

(A) Revision date;

(B) Tag lines in English and other languages spoken by substantial populations of MCO members. Substantial is defined as 35 or more households that speak the same language and in which no adult speaks English. The tag lines must describe how members are to access interpreter services including sign interpreters, translations, and materials in other formats;

(C) MCO’s office location, mailing address, web address if applicable, office hours and telephone numbers (including TTY);

(D) How to choose a Primary Care Provider (PCP) or Primary Care Dentist (PCD) and make an appointment, and policy on changing PCPsor PCDs;

(E) How to access information on contracted providers currently accepting new members (which may be through an online provider directory), and any restrictions on the member’s freedom of choice among participating providers;

(F) What services can be self-referred to either participating or non-participating providers (Fully Capitated Health Plans (FCHP), PCOs and Mental Health Organizations (MHO) only);

(G) Policies on referrals for specialty care, including preauthorization requirements and how to request a referral;

(H) Explanation of Exceptional Needs Care Coordination (ENCC) and how members with special health care needs, who are aged, blind or disabled, or who have complex medical needs, can access ENCC services (FCHPs and PCOs);

(I) How and where members are to access urgent care services and advice, including when away from home;

(J) How and when members are to use emergency services both locally and when away from home, including examples of emergencies;

(K) Information on contracted hospitals in the member’s service area;

(L) Information on post-stabilization care after a member is stabilized in order to maintain, improve or resolve the member’s condition;

(M) Member appeal rights, including information on the MCO’s complaint process and information on the Division’s fair hearing procedures;

(N) Information on the member’s rights and responsibilities;

(O) Information on copayments, charges for non-covered services, and the member’s possible responsibility for charges if they go outside of MCO for non-emergent care;

(P) The transitional procedures for new members to obtain prescriptions, supplies and other necessary items and services in the first month of enrollment with the MCO if they are unable to meet with a PCP/ PCD, other prescribing practitioner, or obtain new orders during that period;

(Q) (FCHPs, PCOs and MHOs only) Information on advance directive policies including:

(i) Member rights under federal and Oregon law to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives;

(ii)The contractor’s policies for implementation of those rights, including a statement of any limitation regarding the implementation of advanced directives as a matter of conscience;

(R) Whether or not the MCO uses physician incentives to reduce cost by limiting services;

(S) The member’s right to request and obtain copies of their clinical records (and whether they may be charged a reasonable copying fee), and to request that the record be amended or corrected;

(T) How and when members are to obtain ambulance services (FCHP, MHO and PCO only);

(U) Possible resources for help with transportation to appointments with providers;

(V) Explanation of the covered and non-covered services in sufficient detail to ensure that members understand the benefits to which they are entitled;

(W) How members are to obtain prescriptions including information on the process for obtaining non-formulary and over-the-counter drugs;

(X) MCO’s confidentiality policy;

(Y) How and where members are to access any benefits that are available under the Oregon Health Plan (OHP) but are not covered under the MCO’s’ contract, including any cost sharing;

(Z) When and how members can voluntarily and involuntarily disenroll from OHP managed care and change MCOs.

(c) The MCO shall compile a printed provider directory for distribution to members, which may be part of their member handbook or separate, and shall include currently contracted provider names and specialty, non-English languages spoken, office location, telephone numbers including TTY, office hours, and accessibility for members with disabilities;

(d) If the MCO handbook is returned with a new address, the MCO shall re-mail the handbook to the new address;

(e) MCOs shall, at a minimum, annually review their member handbook for accuracy and update it with new and corrected information as needed to reflect OHP program changes and the MCO’s internal changes. If changes impact the member’s ability to use services or benefits, the updated member handbook shall be offered to all members;

(f) The “Oregon Health Plan Client Handbook” is in addition to the MCO’s member handbook and cannot be used to substitute for any component of the MCO’s member handbook.

(4) Member health education shall include:

(a) Information on specific health care procedures, instruction in self-management of health care, promotion and maintenance of optimal health care status, patient self-care, and disease and accident prevention. Health education may be provided by MCO’s practitioners or other individuals or programs approved by the MCO. MCOs shall endeavor to provide health education in a culturally sensitive manner in order to communicate most effectively with individuals from non-dominant cultures.

(b) MCOs shall ensure development and maintenance of an individualized health educational plan for members who have been identified by their practitioner as requiring specific educational intervention. The Oregon Health Authority (Authority) may assist in developing materials that address specifically identified health education problems to the population in need.

(c) Explanation of Exceptional Needs Care Coordination (ENCC) and how to access ENCC, through outreach to members with special health care needs, who are aged, blind or disabled, or who have complex medical needs;

(d) The appropriate use of the delivery system, including proactive and effective education of members on how to access Emergency Services and Urgent Care Services appropriately;

(e) MCOs shall provide written notice to affected members of any significant changes in program or service sites that impact the members’ ability to access care or services from MCO’s participating providers. Such notice shall be provided at least 30 calendar days prior to the effective date of that change, or as soon as possible if the participating provider(s) has not given the MCO sufficient notification to meet the 30 days notice requirement. The Division or AMH will review and approve such materials within two working days.

(5) Informational materials that MCOs develop for members shall meet the language requirements of, and be culturally sensitive to, members with disabilities or reading limitations, including substantial populations whose primary language is not English;

(a) MCOs shall be required to translate materials for substantial populations of non-English speaking members in the MCO’s caseload. Substantial is defined as follows: 35 or more households that speak the same non-English language and in which no adult speaks English. The MCO shall be required to provide informational materials which at a minimum shall include the member handbook in the primary language of each substantial population. Alternative forms may include, but are not limited to audio recordings, close-captioned videos, large type and Braille;

(b) Form correspondence sent to members, including but not limited to, enrollment information, choice and member counseling letters and notices of action to deny, reduce or stop a benefit shall include instructions in the language of each substantial population of non-English speaking members on how to receive an oral or written translation of the material;

(c) All written informational materials and identification (ID) cards distributed to members shall be written at the sixth grade reading level and printed in 12 point font or larger;

(6) MCOs shall provide an ID card to members, unless waived by the Division or AMH, which contains simple, readable and usable information on how to access care in an urgent or emergency situation. Such ID cards shall confer no rights to services or other benefits under the OHP and are solely for the convenience of the PHP, members and providers.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS ORS 413.042

Stats. Implemented: ORS 414.725

Hist.: HR 31-1993, f. 10-14-93, cert. ef. 2-1-94; HR 39-1994, f. 12-30-94, cert. ef. 1-1-95; HR 19-1996, f. & cert. ef. 10-1-96; HR 25-1997, f. & cert. ef. 10-1-97; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 29-2001, f. 8-13-01, cert. ef. 10-1-01; OMAP 57-2002, f. & cert. ef. 10-1-02; OMAP 50-2003, f. 7-31-03 cert. ef 8-1-03; OMAP 37-2004(Temp), f. 5-27-04 cert. ef. 6-1-04 thru 11-15-04; OMAP 47-2004, f. 7-22-04 cert. ef. 8-1-04; OMAP 27-2005, f. 4-20-05, cert. ef. 5-1-05; OMAP 46-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 23-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 16-2010, f. 6-11-10, cert. ef. 7-1-10; DMAP 42-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 29-2011, f. 10-19-11, cert. ef. 10-20-11

410-141-0420

Managed Care Prepaid Health Plan Billing and Payment under the Oregon Health Plan

The Division of Medical Assistance Programs (Division) may have specific definitions for common terms. Please use OAR 410-141-0000, Definitions, in conjunction with this rule.

(1) Providers must submit all billings for Oregon Health Plan (OHP) clients to Prepaid Health Plans (PHPs) and to the Division within four (4) months and twelve (12) months, respectively, of the date of service, subject to other applicable Division billing rules. Providers must submit billings to PHPs within the four (4) month time frame except in the following cases:

(a) Pregnancy;

(b) Eligibility issues such as retroactive deletions or retroactive enrollments;

(c) Medicare is the primary payer;

(d) Other cases that could have delayed the initial billing to the PHP (which does not include failure of provider to certify the Division member’s (see definition) eligibility); or

(e) Third Party Liability (TPL). Pursuant to 42 CFR 36.61, subpart G: Indian Health Services and the amended Public Law 93-638 under the Memorandum of Agreement that Indian Health Service and 638 Tribal Facilities are the payer of last resort and is not considered an alternative liability or TPL.

(2) Providers must be enrolled with the Division to be eligible for Division fee-for-service (FFS) payments. Mental health providers, except Federally Qualified Health Centers (FQHC), must be approved by the Local Mental Health Authority (LMHA) and the Addictions and Mental Health (AMH) Division before enrollment with the Division or to be eligible for PHP payment for services. Providers may be retroactively enrolled, in accordance with OAR 410-120-1260, Provider Enrollment.

(3) Providers, including mental health providers (see definition), must be enrolled with the Division either as a Medicaid provider or an encounter-only provider prior to submission of encounter data to ensure the servicing provider is not excluded per federal and State standard as defined in OAR 407-120-0300.

(4) Providers shall verify, before rendering services, which Division member is eligible for the Medical Assistance Program on the date of service using the Division tools and optionally the PHP’s tools, as applicable and that the service to be rendered is covered under the Oregon Health Plan Benefit Package of covered services. Providers shall also identify the party responsible for covering the intended service and seek pre-authorizations from the appropriate payer before rendering services. Providers shall inform Division members of any charges for non-covered services (see definition) prior to the services being delivered.

(5) Capitated services:

(a) PHPs receive a capitation payment to provide services to Division members. These services are referred to as capitated services;

(b) PHPs are responsible for payment of all capitated services. Such services should be billed directly to the PHP, unless the PHP or the Division specifies otherwise. PHPs may require providers to obtain preauthorization to deliver certain capitated services.

(6) Payment by the PHP to participating providers for capitated services is a matter between the PHP and the participating provider, except as follows:

(a) Pre-authorizations:

(A) PHPs shall have written procedures for processing pre-authorization requests received from any provider. The procedures shall specify time frames for:

(i) Date stamping pre-authorization requests when received;

(ii) Determining within a specific number of days from receipt whether a pre-authorization request is valid or non-valid;

(iii) The specific number of days allowed for follow up on pended preauthorization requests to obtain additional information;

(iv)The specific number of days following receipt of the additional information that a redetermination must be made;

(v) Providing services after office hours and on weekends that require preauthorization;

(vi) Sending notice of the decision with appeal rights to the Division member when the determination is made to deny the requested service as specified in 410-141-0263.

(B) PHPs shall make a determination on at least 95% of valid preauthorization requests, within two working days of receipt of a preauthorization or reauthorization request related to urgent services; alcohol and drug services; and/or care required while in a skilled nursing facility. Preauthorization for prescription drugs must be completed and the pharmacy notified within 24 hours. If a preauthorization for a prescription cannot be completed within the 24 hours, the PHP must provide for the dispensing of at least a 72-hour supply if the medical need for the drug is immediate. PHP shall notify providers of such determination within 2 working days of receipt of the request;

(C) For expedited prior authorization requests in which the provider indicates, or the PHP determines, that following the standard timeframe could seriously jeopardize the Division member’s life or health or ability to attain, maintain, or regain maximum function:

(i) The PHP must make an expedited authorization decision and provide notice as expeditiously as the Division member’s health condition requires and no later than three working days after receipt of the request for service;

(ii) The PHP may extend the three working days time period by up to 14 calendar days if the Division member requests an extension, or if the PHP justifies to Division a need for additional information and how the extension is in the Division member’s interest.

(D) For all other preauthorization requests, PHPs shall notify providers of an approval, a denial or a need for further information within 14 calendar days of receipt of the request. PHPs must make reasonable efforts to obtain the necessary information during that 14-day period. However, the PHP may use an additional 14 days to obtain follow-up information, if the PHP justifies (to the Division upon request) the need for additional information and how the delay is in the interest of the Division member. The PHP shall make a determination as the Division member’s health condition requires, but no later than the expiration of the extension.

(b) Claims payment:

(A) PHPs shall have written procedures for processing claims submitted for payment from any source. The procedures shall specify time frames for:

(i) Date stamping claims when received;

(ii) Determining within a specific number of days from receipt whether a claim is valid or non-valid;

(iii) The specific number of days allowed for follow up of pended claims to obtain additional information;

(iv) The specific number of days following receipt of additional information that a determination must be made; and

(v) Sending notice of the decision with appeal rights to the Division member when the determination is made to deny the claim.

(B) PHPs shall pay or deny at least 90% of valid claims within 45 calendar days of receipt and at least 99% of valid claims within 60 calendars days of receipt. PHPs shall make an initial determination on 99% of all claims submitted within 60 calendar days of receipt;

(C) PHPs shall provide written notification of PHP determinations when such determinations result in a denial of payment for services, for which the Division member may be financially responsible. Such notice shall be provided to the Division member and the treating provider within 14 calendar days of the final determination. The notice to the Division member shall be a Division or AMH approved notice format and shall include information on the PHPs internal appeals process, and the Notice of Hearing Rights (DMAP 3030) shall be attached. The notice to the provider shall include the reason for the denial;

(D) PHPs shall not require providers to delay billing to the PHP;

(E) PHPs shall not require Medicare be billed as the primary insurer for services or items not covered by Medicare, nor require non-Medicare approved providers to bill Medicare;

(F) PHPs shall not deny payment of valid claims when the potential TPR is based only on a diagnosis, and no potential TPR has been documented in the Division member’s clinical record;

(G) PHPs shall not delay nor deny payments because a co-payment was not collected at the time of service.

(c) FCHPs, PCOs, and MHOs are responsible for payment of Medicare coinsurances and deductibles up to the Medicare or PHP’s allowable for covered services the Division member receives within the PHP, for authorized referral care, and for urgent care services or emergency services the Division member receives from non-participating providers (see definition). FCHPs, PCOs, and MHOs are not responsible for Medicare coinsurances and deductibles for non-urgent or non-emergent care Division members receive from non-participating providers;

(d) FCHPs and PCOs shall pay transportation, meals and lodging costs for the Division member and any required attendant for out-of-state services (as defined in General Rules, chapter 410, division 120) that the FCHP and PCO has arranged and authorized when those services are available within the state, unless otherwise approved by the Division;

(e) PHPs shall be responsible for payment of covered services (see definition) provided by a non-participating provider which was not pre-authorized if the following conditions exist:

(A) It can be verified that the participating provider (see definition) ordered or directed the covered services to be delivered by a non-participating provider; and

(B) The covered service was delivered in good faith without the pre-authorization; and

(C) It was a covered service that would have been pre-authorized with a participating provider if the PHP’s referral protocols had been followed;

(D) The PHP shall be responsible for payment to non-participating providers (providers enrolled with the Division that do not have a contract with the PHP) for covered services that are subject to reimbursement from the PHP, the amount specified in OAR 410-120-1295. This rule does not apply to providers that are Type A or Type B hospitals, as they are paid in accordance with ORS 414.727.

(7) Other services:

(a) Division members enrolled with PHPs may receive certain services on a Division FFS basis. Such services are referred to as non-capitated services (see definition);

(b) Certain services must be authorized by the PHP or the Community Mental Health Program (CMHP) for some mental health services, even though such services are then paid by the Division on a Division FFS basis. Before providing services, providers should verify a Division member’s eligibility via the web portal or AVR. For some mental health services, providers will need to contact the CMHP directly. In addition, the provider may call the PHP to obtain information about coverage for a particular service or pre-authorization requirements;

(c) Services authorized by the PHP or CMHP are subject to the rules and limitations of the appropriate Division administrative rules and supplemental information, including rates and billing instructions;

(d) Providers shall bill the Division directly for non-capitated services in accordance with billing instructions contained in the Division administrative rules and supplemental information;

(e) The Division shall pay at the Medicaid FFS rate in effect on the date the service is provided subject to the rules and limitations described in the relevant rules, contracts, billing instructions and Division administrative rules and supplemental information;

(f) The Division shall not pay a provider for provision of services for which a PHP has received a capitation payment unless otherwise provided for in OAR 410-141-0120;

(g) When an item or service is included in the rate paid to a medical institution, a residential facility or foster home, provision of that item or service is not the responsibility of the Division, AMH, nor a PHP except as provided for in Division administrative rules and supplemental information (e.g., capitated services that are not included in the nursing facility all-inclusive rate);

(h) FCHPs and PCOs that contract with FQHCs and RHCs shall negotiate a rate of reimbursement that is not less than the level and amount of payment which the FCHP or PCO would make for the same service(s) furnished by a provider, who is not an FQHC nor RHC, consistent with the requirements of BBA 4712(b)(2).

(8) Coverage of services through the Oregon Health Plan Benefit Package of covered services is limited by OAR 410-141-0500, excluded services and limitations for OHP clients.

(9) OHP clients who are enrolled with a PCM receive services on a FFS basis:

(a) PCMs are paid a per client-per month payment to provide Primary Care Management Services, in accordance with OAR 410-141-0410, Primary Care Manager Medical Management;

(b) PCMs provide primary care access, and management services for preventive services, primary care services, referrals for specialty services, limited inpatient hospital services and outpatient hospital services. The Division payment for these PCM managed services is contingent upon PCCM authorization;

(c) All PCM managed services are covered services that shall be billed directly to the Division in accordance with billing instructions contained in the Division administrative rules and supplemental information;

(d) The Division shall pay at the Division FFS rate in effect on the date the service is provided subject to the rules and limitations described in the appropriate Division administrative rules and supplemental information.

(10) All OHP clients who are enrolled with a PCO receive inpatient hospital services on a Division FFS basis:

(a) May receive services directly from any appropriately enrolled Division provider;

(b) All services shall be billed directly to the Division in accordance with FFS billing instructions contained in the Division administrative rules and supplemental information;

(c) The Division shall pay at the Division FFS rate in effect on the date the service is provided subject to the rules and limitations described in the appropriate Division administrative rules and supplemental information.

(11) OHP clients who are not enrolled with a PHP receive services on a Division FFS basis:

(a) Services may be received directly from any appropriate enrolled Division provider;

(b) All services shall be billed directly to the Division in accordance with billing instructions contained in the Division administrative rules and supplemental information;

(c) The Division shall pay at the Division FFS rate in effect on the date the service is provided subject to the rules and limitations described in the appropriate Division administrative rules and supplemental information.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 31-1993, f. 10-14-93, cert. ef. 2-1-94; HR 7-1994, f. & cert. ef. 2-1-94; HR 17-1995, f. 9-28-95, cert. ef. 10-1-95; HR 19-1996, f. & cert. ef. 10-1-96; HR 25-1997, f. & cert. ef. 10-1-97; OMAP 21-1998, f. & cert. ef. 7-1-98; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 26-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 15-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 52-2001, f. & cert. ef. 10-1-01; OMAP 57-2002, f. & cert. ef. 10-1-02; OMAP 4-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 61-2003, 9-5-03, cert. ef. 10-1-03; OMAP 23-2004(Temp), f. & cert. ef. 3-23-04 thru 8-15-04; OMAP 33-2004, f. 5-26-04, cert. ef. 6-1-04; OMAP 37-2004(Temp), f. 5-27-04 cert. ef. 6-1-04 thru 11-15-04; OMAP 47-2004, f. 7-22-04 cert. ef. 8-1-04; OMAP 27-2005, f. 4-20-05, cert. ef. 5-1-05; OMAP 46-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 23-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 53-2006(Temp), f. 12-28-06, cert. ef. 1-1-07 thru 6-29-07; DMAP 9-2007, f. 6-14-07, cert. ef. 6-29-07; DMAP 45-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 16-2010, f. 6-11-10, cert. ef. 7-1-10; DMAP 42-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 29-2011, f. 10-19-11, cert. ef. 10-20-11

Rule Caption: Non-Participating Provider retroactive reimbursement change.

Adm. Order No.: DMAP 30-2011(Temp)

Filed with Sec. of State: 10-20-2011

Certified to be Effective: 10-20-11 thru 3-25-12

Notice Publication Date:

Rules Amended: 410-120-1295

Subject: The General Rules Program administrative rules govern the Division payments for services provided to clients. The Division temporarily amended OAR 410-120-1295 effective to October 1, 2011, to allow providers to be reimbursed at the correct rate for services rendered on or after Oct. 1. The formula established by the reimbursement methodology in ORS 414.743 gives correct and appropriate information to hospitals and managed care organizations when applying the formula to claims for reimbursement for services rendered to medical assistance clients. The statute is based on the budget period that coordinates with the managed care and Division contracts. The Division intends to permanently amend this rule.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-120-1295

Non-Participating Provider

(1) For purposes of this rule, a provider enrolled with the Division of Medical Assistance Programs (Division) that does not have a contract with a Division-contracted Prepaid Health Plan (PHP) is referred to as a non-participating provider.

(2) For covered services that are subject to reimbursement from the PHP, a non-participating provider, other than a hospital governed by (3) below, must accept from the Division-contracted PHP, 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 Fully Capitated Health Plan (FCHP) 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 FCHP will 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 capitation rates paid to the FCHP for the contract period (ORS 414.727);

(b) All other non-participating hospitals (not designated as a rural access or Type A and Type B hospital): As specified in ORS 414.743, the FCHP shall reimburse inpatient and outpatient services using a Medicare payment methodology at a designated percentage point less than the percentage of Medicare costs used by the Oregon Health Authority (Authority) when calculating the base hospital capitation payment to FCHP’s, excluding any supplemental payments:

(i) 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;

(ii) 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.

(4) A non-participating hospital must notify the FCHP within 2 business days of an FCHP patient admission when the FCHP is the primary payer. Failure to notify does not, in and of itself, result in denial for payment. The FCHP is required to review the hospital claim for:

(a) Medical appropriateness;

(b) Compliance with emergency admission or prior authorization policies;

(c) Member’s benefit package;

(d) The FCHP contract and the Division’s administrative rules.

(5) After notification from the non-participating hospital, the FCHP may:

(a) Arrange for a transfer to a contracted facility, if the patient is medically stable and the FCHP has secured another facility to accept the patient;

(b) Perform concurrent review; and/or

(c) Perform case management activities.

(6) In the event of a disagreement between the FCHP and hospital, the provider may appeal the decision by asking for an administrative review as specified in OAR 410-120-1580.

Stat. Auth.: ORS 409.040, 409.050& 414.065

Stats. Implemented: ORS 414.025, 414.065, 414.705 & 414.743

Hist.: OMAP 10-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 22-2004, f. & cert. ef. 3-22-04; OMAP 23-2004(Temp), f. & cert. ef. 3-23-04 thru 8-15-04; OMAP 33-2004, f. 5-26-04, cert. ef. 6-1-04; OMAP 75-2004(Temp), f. 9-30-04, cert. ef. 10-1-04 thru 3-15-05; OMAP 4-2005(Temp), f. & cert. ef. 2-9-05 thru 7-1-05; OMAP 33-2005, f. 6-21-05, cert. ef. 7-1-05; OMAP 35 2005, f. 7-21-05, cert. ef. 7-22-05; OMAP 49-2005(Temp), f. 9-15-05, cert. ef. 10-1-05 thru 3-15-06; OMAP 63-2005, f. 11-29-05, cert. ef. 1-1-06; OMAP 66-2005(Temp), f. 12-13-05, cert. ef. 1-1-06 thru 6-28-06; OMAP 72-2005(Temp), f. 12-29-05, cert. ef. 1-1-06 thru 6-28-06; OMAP 28-2006, f. 6-22-06, cert. ef. 6-23-06; OMAP 42-2006(Temp), f. 12-15-06, cert. ef. 1-1-07 thru 6-29-07; DMAP 2-2007, f. & cert. ef. 4-5-07; DMAP 24-2007, f. 12-11-07 cert. ef. 1-1-08; DMAP 28-2009(Temp), f. 9-11-09, cert. ef. 10-1-09 thru 3-25-10; DMAP 35-2009(Temp), f. & cert. ef. 12-4-09 thru 3-25-10; DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 4-2010, f. & cert. ef. 3-26-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 30-2011(Temp), f. & cert. ef. 10-20-11 thru 3-25-12

Rule Caption: Hospital Provider Tax Rate Change.

Adm. Order No.: DMAP 31-2011

Filed with Sec. of State: 10-28-2011

Certified to be Effective: 11-1-11

Notice Publication Date: 10-1-2011

Rules Amended: 410-050-0861

Rules Repealed: 410-050-0861(T)

Subject: The hospital provider tax rate is 5.08%, effective October 1, 2011. This permanent rulemaking action repeals the temporary rules in effect since July 1, 2011 where the provider tax rate was adjusted from 2.32% to 5.25% and then from 5.25% to 5.08%.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-050-0861

Tax Rate

(1) The tax rate for the period beginning January 1, 2005 and ending June 30, 2006 is .68 percent.

(2) The tax rate for the period beginning July 1, 2006 and ending December 31, 2007 is .82 percent.

(3) The tax rate for the period beginning January 1, 2008 and ending June 30, 2009 is .63 percent.

(4) The tax rate for the period of January 1, 2008 through June 30, 2009 does not apply to the period beginning July 1, 2009.

(5) The tax rate for the period beginning July 1, 2009 and ending September 30, 2009 is .15 percent.

(6) The tax rate for the period beginning October 1, 2009 and ending June 30, 2010 is 2.8 percent.

(7) The tax rate for the period beginning July 1, 2010 and ending June 30, 2011 is 2.32 percent.

(8) The tax rate for the period beginning July 1, 2011 and ending September 30, 2011 is 5.25 percent.

(9) The tax rate for the period beginning October 1, 2011 is 5.08 percent.

Stat. Auth.: ORS 413.042

Stats. Implemented: 2009 OL Ch. 867 §17, 2007 OL Ch. 780 §1 & 2003 OL Ch. 736 § 2 & 3

Hist.: OMAP 28-2005(Temp), f. & cert. ef. 5-10-05 thru 11-5-05; OMAP 34-2005, f. 7-8-05, cert. ef. 7-11-05; OMAP 14-2006, f. 6-1-06, cert. ef. 7-1-06; DMAP 29-2007, f. 12-31-07, cert. ef. 1-1-08; DMAP 3-2008, f. & cert. ef. 1-25-08; DMAP 24-2009, f. & cert. ef. 7-1-09; DMAP 25-2009(Temp), f. & cert. ef. 7-15-09 thru 1-10-10; DMAP 27-2009, f. & cert. ef. 9-1-09; DMAP 33-2009, f. & cert. ef. 10-1-09; DMAP 21-2010, f. 6-30-10, cert. ef. 7-1-10; DMAP 16-2011(Temp), f. & cert. ef. 7-1-11 thru 11-1-11; DMAP 26- 2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 11-1-11; DMAP 31-2011, f. 10-28-11, cert. ef. 11-1-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

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