Oregon Administrative Rules
Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS
Division 165 - OREGON MEDICAID ELECTRONIC HEALTH RECORD (EHR) INCENTIVE PROGRAM
Section 410-165-0100 - Participation and Incentive Payments
Universal Citation: OR Admin Rules 410-165-0100
Current through Register Vol. 63, No. 9, September 1, 2024
(1) To qualify for an incentive payment, an eligible provider shall meet the Program eligibility criteria and participation requirements for each year the eligible provider applies:
(a) An eligible provider shall meet the
eligibility criteria for each program year of:
(A) Type of eligible provider;
(B) Patient volume minimum; and
(C) Certified EHR technology adoption,
implementation, or upgrade requirements in the first year of participation and
meaningful use requirements in subsequent years, or meaningful use requirements
in all years of participation.
(b) An eligible provider must meet the
participation requirements for each program year including:
(A) Be an enrolled Medicaid provider with the
Division;
(B) Maintain current
provider information with the Division;
(C) Possess an active professional license
and comply with all licensing statutes and regulations within the state where
the eligible provider practices;
(D) Have an active Provider Web Portal
account;
(E) Ensure the designated
payee is able to receive electronic funds transfer from the Authority;
and
(F) Comply with all applicable
Oregon Administrative Rules, including chapter 410, division 120, and chapter
943, division 120.
(c)
An eligible professional may reassign the entire amount of the incentive
payment to:
(A) The eligible professional's
employer with whom the eligible professional has a contractual arrangement
allowing the employer to bill and receive payments for the eligible
professional's covered professional services;
(B) An entity with which the eligible
professional has a contractual arrangement allowing the entity to bill and
receive payments for the eligible professional's covered professional services;
or
(C) An entity promoting the
adoption of certified EHR technology.
(2) An eligible professional shall follow the Program participation conditions and requirements. The eligible professional shall:
(a) Receive an incentive payment from
only one state for a program year;
(b) Only receive an incentive payment from
either Medicare or Medicaid for a program year, but not both;
(c) Not receive more than the maximum
incentive amount of $63,750 over a six-year period or the maximum incentive of
$42,500 over a six-year period if the eligible professional qualifies as a
pediatrician who meets the 20 percent patient volume minimum and less than the
30 percent patient volume;
(d)
Participate in the Program:
(A) Starting as
early as calendar year (CY) 2011, but no later than CY 2016;
(B) Ending no later than CY 2021;
(C) For a maximum of six years; and
(D) On a consecutive or non-consecutive
annual basis.
(e) Be
allowed to switch between the Medicare and Medicaid Programs only one time
after receiving at least one incentive payment and only for a program year
before 2015.
(3) The Authority shall disburse payments to the eligible professional following verification of eligibility for the program year:
(a) An eligible professional is paid an
incentive amount for the corresponding program year for each year of qualified
participation in the Program;
(b)
The payment structure is as follows for:
(A)
An eligible professional qualifying with 30 percent minimum patient volume:
(i) The first payment incentive amount is
$21,250; and
(ii) The second,
third, fourth, fifth, or sixth payment incentive amount is $8,500; or
(B) An eligible pediatrician
qualifying with 20 percent but less than 30 percent minimum patient volume:
(i) The first payment incentive amount is
$14,167; and
(ii) The second,
third, fourth, or fifth payment incentive amount is $5,667;
(iii) The sixth payment incentive amount is
$5,665.
(c)
The deadline for the Authority to disburse payments to eligible professionals
is December 31, 2021.
(4) An eligible hospital shall follow the Medicaid EHR Incentive Program participation conditions including requirements that the eligible hospital:
(a) Receives a
Medicaid EHR incentive payment from only one state for a program
year;
(b) May participate in both
the Medicare and Medicaid EHR Incentive Programs only if the eligible hospital
meets all eligibility criteria for the program year for both
programs;
(c) Participates in the
Program:
(A) Starting as early as program
year 2011 but no later than program year 2016;
(B) Ending no later than program year
2021;
(C) For a maximum of three
years;
(D) On a consecutive or
non-consecutive annual basis for program years prior to program year 2016;
and
(E) On a consecutive annual
basis for program years starting in program year 2016.
(d) A multi-site hospital with one CMS CCN is
considered one hospital for purposes of calculating payment.
(5) The Authority shall disburse payments to the eligible hospital following verification of eligibility for the program year. An eligible hospital is paid the aggregate incentive amount over three years of qualified participation in the Program:
(a) The payment structure as listed in Table
165-0100-1 is as follows:
(A) The first
payment incentive amount is equal to 50 percent of the aggregate EHR
amount;
(B) The second payment
incentive amount is equal to 40 percent of the aggregate EHR amount;
and
(C) The third payment incentive
amount is equal to 10 percent of the aggregate EHR amount.
(b) The aggregate EHR amount is calculated as
the product of the "overall EHR amount" times the "Medicaid Share" as listed in
Table 165-0100-2. The aggregate EHR amount is calculated once for the
first-year participation and then paid over three years according to the
payment schedule:
(A) The overall EHR amount
for an eligible hospital is based upon a theoretical four years of payment the
hospital would receive and is the sum of the following calculation performed
for each of such four years. For each year, the overall EHR amount is the
product of the initial amount, the Medicare share, and the transition factor:
(i) The initial amount as listed in Table
165-0100-3 is equal to the sum of the base amount, which is set at $2,000,000
for each of the theoretical four years plus the discharge-related amount that
is calculated for each of the theoretical four years:
(I) For initial amounts calculated in program
years 2011 or 2012, the discharge-related amount is $200 per discharge for the
1,150th through the 23,000th discharge, based upon the total discharges for the
eligible hospital (regardless of source of payment) from the hospital fiscal
year that ends during the federal fiscal year (FFY) prior to the FFY year that
serves as the first payment year. No discharge-related amount is added for
discharges prior to the 1,150th or any discharges after the 23,000th;
(II) For initial amounts calculated in
program year 2013 or later, the discharge-related amount is $200 per discharge
for the 1,150th through the 23,000th discharge, based upon the total discharges
for the eligible hospital (regardless of source of payment) from the hospital
fiscal year that ends before the FFY that serves as the first payment year. No
discharge-related amount is added for discharges prior to the 1,150th or any
discharges after the 23,000th;
(III) For purposes of calculating the
discharge-related amount for the last three of the theoretical four years of
payment, discharges are assumed to increase each year by the hospital's average
annual rate of growth; negative rates of growth shall also be applied. Average
annual rate of growth is calculated as the average of the annual rate of growth
in total discharges for the most recent three years for which data are
available per year.
(ii)
The Medicare share that equals 1;
(iii) The transition factor that equals:
(I) 1 for the first of the theoretical four
years;
(II) 0.75 for the second of
the theoretical four years;
(III)
0.5 for the third of the theoretical four years; and
(IV) 0.25 for the fourth of the theoretical
four years.
(B) The Medicaid share for an eligible
hospital is equal to a fraction:
(i) The
numerator for the FFY and with respect to the eligible hospital is the sum of:
(I) The estimated number of
inpatient-bed-days that are attributable to Medicaid individuals; and
(II) The estimated number of
inpatient-bed-days that are attributable to individuals who are enrolled in a
managed or coordinated care organization, a pre-paid inpatient health plan, or
a pre-paid ambulatory health plan administered under 42 CFR Part 438.
(ii) The denominator is the
product of:
(I) The estimated total number of
inpatient-bed-days with respect to the eligible hospital during such period;
and
(II) The estimated total amount
of the eligible hospital's charges during such period, not including any
charges that are attributable to charity care, divided by the estimated total
amount of the hospital's charges during such period.
(iii) In computing inpatient-bed-days for the
Medicaid share, an eligible hospital may not include either of the following:
(I) Estimated inpatient-bed-days attributable
to individuals that may be made under Medicare Part A; or
(II) Inpatient-bed-days attributable to
individuals who are enrolled with a Medicare Advantage organization under
Medicare Part C.
(iv) If
an eligible hospital's charity care data necessary to calculate the portion of
the formula for the Medicaid share are not available, the eligible hospital's
data on uncompensated care may be used to determine an appropriate proxy for
charity care but shall include a downward adjustment to eliminate bad debt from
uncompensated care data if bad debt is not otherwise differentiated from
uncompensated care. Auditable data sources shall be used; and
(v) If an eligible hospital's data necessary
to determine the inpatient bed-days attributable to Medicaid managed care
patients are not available, that amount is deemed to equal 0. In the absence of
an eligible hospital's data necessary to compute the percentage of inpatient
bed days that are not charity care as described under subparagraph (B)(ii)(II)
in this section, that amount is deemed to be 1.
(6) The aggregate EHR amount is determined by the state from which the eligible hospital receives its first incentive payment. If a hospital receives incentive payments from other states in subsequent years, total incentive payments received over all payment years of the program can be no greater than the aggregate EHR amount calculated by the state from which the eligible hospital received its first incentive payment.
(7) Table 165-0100-1. [Table not included. See NOTE.]
(8) Table 165-0100-2. [Table not included. See NOTE.]
(9) Table 165-0100-3. [Table not included. See NOTE.]
To view tables referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042 & 414.033
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
