Oregon
Rule Rule 111-080-0065
Hospital Payments


(1)

Except as provided in section (8), the maximum reimbursement amount for each claim subject to ORS 243.879 (Reimbursement methodology for payment to hospitals) and these rules shall be determined by the carrier applying the applicable percentage of the Medicare rate, or the Medicare rate for similar services or supplies, as of the date of service of the claim.

(2)

The carrier shall determine the OEBB member’s cost sharing based upon the lower of the amount allowed by ORS 243.879 (Reimbursement methodology for payment to hospitals) or the carrier’s contracted rate for the provider.

(3)

The following payments shall not be included uner ORS 243.879 (Reimbursement methodology for payment to hospitals)(1) or these rules:

(a)

services or supplies that are not covered by Medicare
(b) services or supplies provided at Ambulatory Surgery Centers
(c) professional services provided in a Hospital.
(4) If a third-party administrator of a self-insured plan provides total fee-for-service payments to an in-network hospital under ORS 243.879 (Reimbursement methodology for payment to hospitals)(1) or (2) that exceed twice the total payments at the Medicare rate for the plan year, the self-insured plan third-party administrator will return the difference to OEBB. Moneys returned to OEBB under this rule will be deposited in the Oregon Educators Revolving Fund for purposes consistent with ORS 243.884 (Oregon Educators Revolving Fund).
(5) If a fully-insured carrier provides total fee-for-service payments to an in-network hospital under ORS 243.879 (Reimbursement methodology for payment to hospitals)(1) or (2) that exceed twice the total payments at the Medicare rate for the plan year, the fully-insured carrier will provide OEBB a credit to fully-insured premium rates equivalent to this difference.
(6) If a third-party administrator of a self-insured plan provides total fee-for-service payments to an out-of-network hospital under ORS 243.879 (Reimbursement methodology for payment to hospitals)(1) or (2) that exceed 1.85 times the total payments at the Medicare rate for the plan year, the self-insured third-party administrator will return the difference to OEBB. Moneys returned to OEBB under this rule will be deposited in the Oregon Educators Revolving Fund for purposes consistent with ORS 243.884 (Oregon Educators Revolving Fund).
(7) If a fully-insured carrier provides total fee-for-service payments to an out-of-network hospital under ORS 243.879 (Reimbursement methodology for payment to hospitals)(1) or (2) that exceed 1.85 times the total payments at the Medicare rate for the plan year, the fully-insured carrier will provide OEBB a credit to fully-insured premium rates equivalent to this difference.
(8) If a carrier or third-party administrator does not reimburse hospitals on a fee-for-service basis, it may pursue an alternative payment method that maintains total payments while taking into account the limits established in ORS 243.879 (Reimbursement methodology for payment to hospitals) and described in this rule, including, but not limited to:
(a) value based payments,
(b) capitation payments and
(c) bundled payments. A carrier or third-party administrator using alternative payment methods must provide actuarial calculations that show the payment methods used adhere to the limits specified in ORS 243.879 (Reimbursement methodology for payment to hospitals). Such alternative payment methods must be reported to OEBB as part of its benefit plan agreement with the carrier or third-party administrator. If payments under the alternative payment arrangement exceed the limits specified in ORS 243.879 (Reimbursement methodology for payment to hospitals) the carrier or third-party administrator will return the difference to OEBB. Moneys returned to OEBB under this rule will be deposited in the Oregon Educators Revolving Fund for purposes consistent with ORS 243.884 (Oregon Educators Revolving Fund).
(9) For purposes of this rule, the “Medicare rate” is the amount of reimbursement for a claim that would be paid as if Medicare reimbursed the claim. Therefore, the outpatient reimbursements apply the Medicare Ambulatory Payment Classification (APC) or Hospital Outpatient Prospective Payment System (OPPS), and that for inpatient the reimbursements apply Medicare Severity Diagnosis Related Groups (MS-DRG). All rebates, incentives, or adjustments that would have applied if reimbursed by Medicare would also apply.
 
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Last accessed
Jul. 9, 2020