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)
Universal Citation: OR Admin Rules 309-015-0025
Current through Register Vol. 63, No. 9, September 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.
(2) Final settlement process. The final settlement process will be as follows:
(a) Upon receipt of the final Medicare Cost
Report from the Medicare Intermediary, the hospital provider will prepare the
final Medicaid cost report. The Medicaid report will reflect all relevant
adjustments made to the Medicare cost report;
(b) Using the final Medicaid cost report
developed in subsection (a) of this section, the Division will calculate the
final settlement rate and settlement for each participating hospital, separate
cost entity or distinct program within a hospital, following the steps outlined
in subsections (1)(a) through (d) of this rule.
(3) Upon completion of each settlement, both year-end and final, the Division will review the disproportionate share costs and make any necessary adjustments to quarterly disproportionate share payments. The Division will review all factors relevant to the disproportionate share payments, including actual costs of services, amounts already paid and charges reimbursed from other sources during the time period included in the Medicaid cost settlement.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025 & 414.065
Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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