OAR 309-015-0005
Definitions
(1)
“Active Treatment” means implementation of a professionally developed and supervised plan of care that is in effect within 14 days of admission and designed to achieve the patient’s discharge at the earliest possible time. Custodial care is not active treatment.(2)
“Actual Costs” means all legitimate Medicaid expenditures. Since Oregon’s Addictions and Mental Health Division utilizes Medicare cost finding principles, actual costs will be the same as “Medicaid Allowable Costs” as defined in this rule.(3)
“Allowable Costs” means the costs applicable to the provision of psychiatric inpatient services as described in OAR 309-015-0050 (Auditing)(3). They are derived using the Medicare cost finding principles located in the Medicare Provide Reimbursement Manual.(4)
“Annual Cost Report” means a financial report submitted to the Medicare/Medicaid Fiscal Intermediary by a hospital, on forms provided by the Fiscal Intermediary. This report details the actual revenues and expenses of the hospital during the latest fiscal period.(5)
“Base Year” means July 1, 1981 through June 30, 1982.(6)
“Disproportionate Share Adjusted Medicaid Rate” (DSR) means the weighted average Medicaid per diem rate (interim, year-end settlement or final settlement) for disproportionate share hospitals. This rate does not include the disproportionate share payment of uncompensated costs of participating hospital programs as provided in these rules.(7)
“Disproportionate Share Costs” means costs that are reimbursable under federal disproportionate share statutes and regulations. These costs are limited to costs of participating hospital programs which have not already been reimbursed by Medicare, Medicaid, insurance, or the patient’s own resources.(8)
“Disproportionate Share Hospital” means a psychiatric hospital which has a low income utilization rate exceeding 25 percent as described in OAR 309-015-0035 (Payments)(5).(9)
“Disproportionate Share Payment” means the payment made quarterly to reimburse participating hospital programs for disproportionate share costs. This payment is subject to recalculation at the time of each year-end or final settlement payment.(10)
“Distinct Program” means a specialized inpatient psychiatric treatment program with unique admission standards approved by the Division. If a participating psychiatric hospital has a specialized program based upon patient age or medical condition, contains 50 or more beds, has a nursing staff specifically assigned to the program which has experience or training in working with the specialized population, and has record keeping systems adequate to separately account for expenditures and revenue to that program relative to the entire hospital, the Division may approve it as a distinct program.(11)
“Division” means the Addictions and Mental Health Division of the Oregon Health Authority.(12)
“Fiscal Intermediary” means:(a)
Blue Cross of Oregon for Medicare, Parts A and B; and(b)
Division for Medicaid services provided under the provisions of this rule;(c)
The Division’s Assistant Administrator for Administrative Services, is the designated Fiscal Intermediary.(13)
“Inpatient Psychiatric Services” means active treatment services provided under the direction of a licensed physician by a participating psychiatric hospital.(14)
“Interim Per Diem Rate” means the daily rate established with and paid to each provider for the agreement period during which reimbursable services are to be provided.(15)
“Low Income Utilization Rate” means the sum of the ratio of a hospital’s Medicaid revenues (plus governmental subsidies) to total revenue added to the ratio of a hospital’s proportion of charity care expenditures (less governmental subsidies) to total inpatient psychiatric services charges (as outlined in OAR 309-015-0035 (Payments)(5)).(16)
“Maximum Allowable Rate” means the statewide average per diem cost for services as derived in accordance with OAR 309-015-0020 (Establishing the Base Year and the Initial Maximum Allowable Rate) and 309-015-0021 (Establishing the Maximum Allowable Rate for Years Following the Base Period).(17)
“Medicaid” means Title XIX of the Social Security Act.(18)
“Medicaid Allowable Costs” means that portion of total costs determined to be eligible for Medicaid reimbursement. Medicaid allowable costs are determined based on the amount of allowable cost for inpatient services by making the following calculations:(a)
For all providers, determine the reasonable cost of covered services furnished by multiplying the ratio of Medicaid patient days to total patient days by total allowable inpatient costs;(b)
For proprietary providers, determine the allowable return on equity capital invested and used for the provision of patient care by following the general rule outlined in 42 CFR 413.157(b);(c)
Adding the results of the calculations in subsections (a) and (b) of this section to establish the full Medicaid allowable cost.(19)
“Medicaid Intermediary” for the purpose of services provided under this rule, means the Assistant Administrator for Administrative Services, Addictions and Mental Health Division.(20)
“Medicaid Patient Days” means the accumulated total number of days, including therapeutic leave days, during which psychiatric inpatient services were provided to Medicaid eligible patients during a cost reporting period. The Fiscal Intermediary shall determine the total number of Medicaid patient days on the basis of dates of service per patient by provider and fiscal period.(21)
“Medicaid Inpatient Utilization Rate” means the following fraction (expressed as a percentage) for a hospital:(a)
“Numerator”: The hospital’s number of inpatient days attributable to patients who (for such days) were eligible for Title XIX medical assistance under the state Medicaid plan and for whom the Division of Medical Assistance Programs made payment during the fiscal period;(b)
“Denominator”: The total number of the hospital’s inpatient days for the same period.(22)
“Medicare Market Basket Percentage Increase” means the annual allowable increase factor for a standard array of hospital services nationwide as published annually by the Health Care Financing Administration. The percentage is a component of the “Target Rate Percentage Increase” as defined in section (29) of this rule.(23)
“Non-Allowable Costs” means any costs excluded under the provisions of state and federal statutes, regulations, and administrative rules.(24)
“Participating Psychiatric Hospital” means those portions of a licensed psychiatric hospital certified to provide services to Medicaid patients.(25)
“Patient Eligibility” means persons eligible for medical assistance under Medicaid who meet the criteria for admission to psychiatric hospital inpatient services as defined in these rules and OAR 309-031-0200 through 309-031-0255.(26)
“Resident in the Hospital” means a patient who is in the facility at least 12 hours of each day, including the hours of sleep. The day of admission is exempt from this 12 hour rule; however, to be counted for residence purposes, the day of admission must extend through midnight (2,400 hours). The day of discharge is not counted.(27)
“Sanction” means:(a)
Termination of contract with the Division to provide psychiatric hospital services for Medicaid eligible patients;(b)
Suspension of contract with the Division to provide psychiatric hospital services for Medicaid eligible patients; or(c)
Suspension or withholding of payments to a provider. (See OAR 309-015-0052 (Provider Sanctions) for further information.)(28)
“Separate Cost Entity” means an entity of a hospital for which Medicare has approved the submission of a separate cost report.(29)
“Target Rate Percentage Increase” means the annual allowable increase factor applied to the previous year’s maximum allowable rate for psychiatric hospitals and hospital units excluded from the prospective payment system. This percentage includes the Medicare market basket percentage increase as a component and is published annually by the Health Care Financing Administration.(30)
“Therapeutic Leave Days” means a planned and medically authorized period of absence from the hospital not exceeding 72 hours in seven consecutive days.(31)
“Total Patient Days” means the accumulated total number of days, excluding non-Medicaid therapeutic leave days, during which psychiatric inpatient services were provided to patients during a cost reporting period. The fiscal intermediary shall determine the total number of patient days on the basis of dates of service per patient by provider and fiscal period.
Source:
Rule 309-015-0005 — Definitions, https://secure.sos.state.or.us/oard/view.action?ruleNumber=309-015-0005.