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Published: 2015

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The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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OREGON HEALTH AUTHORITY,

ADDICTIONS AND MENTAL HEALTH DIVISION: MENTAL HEALTH SERVICES

 

DIVISION 15
MEDICAID PAYMENT FOR PSYCHIATRIC HOSPITAL INPATIENT SERVICES
 

309-015-0000
Purpose and Statutory
Authority
(1) Purpose. These rules prescribe
the eligibility criteria, methods, and standards for payments to psychiatric hospitals
through the Division of Medical Assistance Programs, Oregon Health Authority. The
rules apply to provision of psychiatric hospital inpatient services for persons
eligible for medical assistance under Medicaid (Title XIX of the Social Security
Act).
(2) Statutory Authority. These
rules are authorized by ORS 413.042 and carry out the provisions of ORS 414.025,
414.065, and 414.085 and Title XIX of the Social Security Act and 42 CFR 441, Subparts
C and D.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 12-1985(Temp), f. &
ef. 7-1-85; MHD 7-1987, f. & ef. 12-30-87; MHD 12-1990, f. & cert. ef. 10-15-90;
MHD 2-1994, f. & cert. ef. 2-24-94
309-015-0005
Definitions
As used in these rules:
(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(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(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(5)).
(16) “Maximum Allowable
Rate” means the statewide average per diem cost for services as derived in
accordance with OAR 309-015-0020 and 309-015-0021.
(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 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.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef.
10-15-90; MHD 2-1994, f. & cert. ef. 2-24-94
309-015-0007
General Conditions of
Eligibility and Treatment
In order for payment to be made
by the Division, the following conditions must be met:
(1) Medicaid-eligible age. The
patient must be eligible for Medicaid benefits, be aged 65 or over, aged 20 or under,
or aged 21 and receiving services at the time of reaching age 21.
(2) Written plan of care. A
professionally developed written plan of care for each patient will describe treatment
objectives and prescribe an integrated program of appropriate therapy activities
and experiences designed to improve the patient’s condition to the extent
that inpatient care is no longer necessary.
(3) Unemancipated minor consultation.
If the patient is under 18 years of age and not emancipated, the facility shall
consult with the parent(s), legal guardian or others into whose care or custody
the person will be released following discharge. The consultation shall be documented
in the hospital records.
(4) Conformance with these rules.
The Division has determined that admission and care of the patient who is eligible
for Medicaid benefits is in accordance with these rules and regulations as evidenced
by the hospital record.
(5) Service provider requirements.
The service provider must meet all requirements for participation under OAR 309-015-0010.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 7-1987, f. &
ef. 12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89
309-015-0010
Conditions of Service
Provider Participation
(1) Medicaid certification.
A service provider must be certified by the responsible state or federal authority
as meeting federal Medicaid certification requirements for psychiatric hospital
inpatient services.
(2) Written agreement with the
Division. A service provider must provide medically prescribed psychiatric hospital
inpatient services to patients eligible for Medicaid benefits under terms of a written
agreement with the Division. The agreement must assure that the psychiatric hospital
and the services provided comply with all applicable state and federal requirements.
No billing for Medicaid payment will be paid until a service provider has fully
executed a written agreement with the Division.
(3) Legislative compliance.
A service provider must be in compliance with:
(a) Title VI of the Civil Rights
Act of 1964;
(b) Section 504 of the Rehabilitation
Act of 1973;
(c) The Age Discrimination Act
of 1975;
(d) The Americans with Disabilities
Act of 1990; and
(e) Any other applicable federal
and state laws.
(4) Medicaid vendor number.
A service provider must request a vendor number from the Division. No billing for
Medicaid payment will be paid until a service provider has secured a Medicaid vendor
number.
(5) Patient admission. A service
provider must obtain approval for the admission of patients to the psychiatric hospital
as required by Addictions and Mental Health Division’s OARs 309-031-0200 through
309-031-0255 (Admission and Discharge of Mentally Ill Persons).
(6) Clinical records. A service
provider must maintain clinical records which are adequate to document the need
for psychiatric hospital inpatient services, and the specific services provided,
including mental health assessment, diagnosis, and treatment plans.
(7) Fiscal records. A service
provider must maintain fiscal records in accordance with generally accepted accounting
principles.
(8) Patient funds. A service
provider must provide an accounting for any funds accepted from the patient for
safekeeping. Such accounts will be available for inspection by personnel designated
by the Division.
(9) Records review. A service
provider must maintain the availability of financial and treatment records for review
without notice by authorized personnel of the Medicaid Intermediary and of the United
States Department of Health and Human Services during normal business hours at the
location of its licensed psychiatric hospital.
(10) Reimbursement for services.
A service provider must accept payment from the Division through the Division of
Medical Assistance Programs as full and total reimbursement for the Medicaid services
provided.
(11) Annual cost reports. A
service provider must submit annually to the Division a Medicaid cost report accompanied
by a copy of the provider’s Medicare cost report.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef.
10-15-90
309-015-0020
Establishing the Base
Year and the Initial Maximum Allowable Rate
(1) Base year. In order to establish
a base year rate, the Medicaid Intermediary used cost statements which overlapped
the base period (July 1, 1981 through June 30, 1982) for all Oregon hospitals who
were either:
(a) Licensed as psychiatric
hospitals on the effective date of these rules (10-1-83) and in operation during
the base period; or
(b) Were applicants for Joint
Commission on Accreditation of Hospitals (JCAH) accreditation as a psychiatric hospital
on the first effective date of these rules and had operated as a licensed hospital
during the base period.
(2) Reporting period adjustments.
If a psychiatric hospital’s cost report was for a period either longer or
shorter than 12 months, the Medicaid allowable costs were reduced or increased,
as appropriate, by multiplying the total allowable costs by the ratio that 12 months
bore to the number of months in the hospital’s report period. This procedure
resulted in a prorated 12-month cost projection for use in establishing the statewide
average per diem rate for the base period.
(3) Inflation factor adjustments.
If a psychiatric hospital had a fiscal period other than the base period, the hospital’s
Medicaid allowable costs were adjusted by applying the relevant inflation factors
from the Medicare market basket index so that the Medicaid costs corresponded to
the base period. The inflation factors were applied to the interval between the
mid-point of the hospital’s fiscal period and the mid-point of the base period.
The number of Medicaid patient days in the hospital’s fiscal period were used
as the number of days in the base period.
(4) Rate calculation. The total
Medicaid allowable costs from all hospitals included in the base period divided
by the total number of Medicaid patient days from all hospitals included in the
base period yielded the statewide average per diem cost (maximum allowable rate)
for the base period.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 6-1989, f. & cert.
ef. 11-17-89
309-015-0021
Establishing the Maximum
Allowable Rate for Years Following the Base Period
(1) Base rate usage. The statewide
average per diem cost for the base period has been used as the fixed base for determining
the maximum allowable reimbursement
rate for all fiscal periods following the base period.
(2) Subsequent period rate calculations.
The maximum allowable reimbursement rate for each new fiscal period affected by
these rules is now calculated by inflating the maximum allowable reimbursement rate
for the previous period by the annual Health Care Financing Administration target
percentages for PPS — excluded hospitals (as published in the Federal Register).
This percentage increase is applied from the mid-point of the previous period to
the mid-point of the 12-month period for which the rate is being established.
(3) Hospitals with other fiscal
periods. When a psychiatric hospital has a fiscal period other than that used by
the State of Oregon, July 1 through June 30, the applicable maximum allowable rate
for each month will be the same as the maximum allowable rate in effect that month
for hospitals operating under the state fiscal period.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 6-1989, f. &
cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef. 10-15-90
309-015-0023
Interim Rate Setting
Rate establishment process.
At least annually, the Medicaid intermediary will establish an interim Medicaid
per diem rate for each participating psychiatric hospital, separate cost entity
or distinct program within a hospital:
(1) A hospital may request an
interim per diem rate or rates. If a review of the hospital’s prior year Medicaid
cost report (adjusted for inflation, changes in patient populations and programs
and other relevant factors) does not justify the requested rate(s), the Medicaid
Intermediary may establish different interim rate(s):
(a) Actual expenditures for
the most recent fiscal period available will be used to determine salary and wage
and total expense distribution for each cost center included in the total expenditures.
Any other directly relevant event, such as facility restructuring, will be considered
as well;
(b) The Division will apply
the proportions from subsection (a) of this section to total anticipated expenditures
for the new period to determine salary and wage expense distribution for each cost
center during the new period;
(c) The Division will establish
and apply capital allowances and other adjustments to total anticipated expenditures
for the new period from subsection (b) of this section;
(d) If the hospital has separate
cost entities or distinct programs, the hospital will provide estimates to the Division
of a weighted average interim rate. The average will be developed by multiplying
each proposed interim rate by estimated Medicaid patient days for that rate, summing
all of the products, and dividing that sum by the total annual estimated Medicaid
patient days for the hospital;
(e) The interim or weighted
average interim per diem rate may not exceed the maximum allowable rate unless the
hospital meets the criteria for reimbursement above the maximum allowable rate as
a disproportionate share hospital (see OAR 309-015-0035(5)). In that case, the interim
or average interim Disproportionate Share adjusted Medicaid Rate (DSR) may include
estimated costs up to 135 percent of the maximum allowable Medicaid rate except
for hospitals meeting criteria set forth in the following paragraph;
(f) If a 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:
(A) Public funds, excluding
Medicare and Medicaid;
(B) Bad debts; or
(C) Free care.
(g) The hospital qualifies to
receive disproportionate share payment at a rate based on 100 percent of the costs
of uncompensated care during the facility’s previous fiscal year, subject
to a disproportionate share allotment established for Oregon by the Health Care
Financing Administration;
(h) The Division will base quarterly
disproportionate share reimbursements on the estimated costs for each facility during
the current fiscal year and will review and adjust the reimbursements, after conclusion
of the fiscal period, to correspond with actual costs encountered during the period.
Total reimbursement from disproportionate share and other sources will not exceed
actual costs.
(2) If a hospital does not request
an interim rate, the Medicaid Intermediary will establish an interim rate based
on the hospital’s prior year cost report using the same factors listed in
section (1) of this rule.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 12-1985(Temp), f. &
ef. 7-1-85; MHD 7-1987, f. & ef. 12-30-87, Renumbered from 309-015-0015; MHD
6-1989, f. & cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef. 10-15-90; MHD
2-1994, f. & cert. ef. 2-24-94
309-015-0025
Retrospective Settlement
Rate Setting (Year End and Final)
(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

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef.
10-15-90; MHD 2-1994, f. & cert. ef. 2-24-94
309-015-0030
Billing Requirements
(1) Bill submission time limits.
Bills shall be submitted to the Division through the Division of Medical Assistance
Programs, on forms designated by the Medicaid Intermediary, as soon as possible
after the date service is rendered. Payment shall not be made for services which
were provided more than 12 months prior to presentation of the claim unless the
hospital shows that the delay was caused by factors outside its control.
(2) Billing charge limits. Billings
to the Division shall in no case exceed the customary charges to private patients
for any like item or service charged by the hospital.
(3) Customary charge criteria.
In determining the customary charges to a private patient for use in billings or
calculating interim or settlement rates, the following criteria will be applied:
(a) The private patient billing
rate must be for items and services comparable to the items and services included
in the rate for Medicaid services;
(b) When private patient rates
are based on the number of beds in a room, the Medicaid intermediary considers the
lowest room charge as the usual and customary charge for services;
(c) When ancillary charges are
made to private patients in addition to a basic charge, the Medicaid Intermediary
considers the usual and customary charge to be the lowest basic room charge plus
the average ancillary charge for those items included in the Medicaid rate. The
average ancillary charge is determined by dividing the ancillary costs by the number
of patient days; or
(d) Where charges are based
on the classification of the patient (i.e., Medicare, Medicaid and Private), the
Medicaid Intermediary considers the usual and customary charge to be the rate for
private patients exclusive of ancillary charges.
(4) Payment restrictions. Payment
will be made only for those days a patient is actually in residence at the hospital
in active treatment or when a patient is on therapeutic leave.
(5) Payment credit. Any payment
received by the hospital prior to the submission of an invoice to the Division of
Medical Assistance Programs shall be indicated as a credit on the invoice.
(6) Post-payment receipt of
funds. Any payments to the provider from any source subsequent to payment by the
Division of Medical Assistance Programs shall be reported to that Division on an
adjustment form specified by the Division of Medical Assistance Programs, giving
full particulars. Failure to report such payments will be considered concealment
of material facts and is grounds for recovery and/or sanction (see OAR 309-015-0052).
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef.
10-15-90; MHD 2-1994, f. & cert. ef. 2-24-94
309-015-0035
Payments
(1) Timing. Payments to providers
will be made following the month of service, based on the invoice submitted by the
provider to the Division of Medical Assistance Programs.
(2) Eligible services. Payments
will be made for the provision of active psychiatric inpatient treatment services
for persons eligible for such services under Medicaid.
(3) Non-eligible services. If
review of a psychiatric hospital’s Medicaid patient records by a Professional
Standards Review Organization reveals that a patient received an inappropriate level
of care, (i.e., less than active treatment), payment will not be allowed under these
rules. Any payments to the provider for patients receiving an inappropriate level
of care shall be recovered by the Division. Such payments shall be reported to the
Division of Medical Assistance Programs on an adjustment form specified by the Division
of Medical Assistance Programs. Failure to report such payments will be considered
concealment of material facts and is grounds for sanction (see OAR 309-015-0052).
(4) Payment to non-disproportionate
share hospitals. The Division shall not pay more in total for psychiatric hospital
inpatient services for hospitals which do not serve a disproportionate number of
low-income patients with special needs than would be paid under the Medicare principles
of reimbursement.
(5) Payment to disproportionate
share hospitals. A participating psychiatric hospital may be reimbursed for allowable
costs in excess of the maximum rate if it meets the following criteria as described
in Section 1923(b)(3) of the Social Security Act: The hospital serves disproportionate
numbers of low-income persons; i.e., has a low income utilization rate which exceeds
25 percent using the following formula:
(a) The total Medicaid in-patient
revenues paid to the hospital, plus the amount of the cash subsidies received as
payment for inpatient services directly from state and local governments in a cost
reporting period, divided by the total amount of revenues of the hospital for in-patient
psychiatric services (including the amount of such cash subsidies) in the same cost
reporting period. The percentage derived in paragraph (a) of this subsection shall
be added to the following percentage;
(b) The total amount of the
hospital’s charges for in-patient psychiatric services attributable to charity
care (care provided to individuals who have no source of payment, third-party or
personal resources) in a cost reporting period, less the portion of any cash subsidies
for in-patient services received directly from state and local governments described
in paragraph (A) of this subsection in the period attributable to in-patient hospital
services, divided by the total amount of the hospital’s charges for in-patient
psychiatric services in the hospital in the same period. The total in-patient charges
attributed to charity care shall not include contractual allowances and discounts
(other than for indigent patients not eligible for Medical Assistance under an approved
Medicaid State Plan);
(c) The sum of percentages derived
in paragraphs (a) and (b) of this subsection shall exceed 25 percent in order to
qualify as a disproportionate share hospital; and
(d)
The hospital is efficiently and economically operated and is in compliance with
treatment and program standards for psychiatric inpatient services as required by
the state and federal statutes and regulations.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef.
10-15-90; MHD 2-1994, f. & cert. ef. 2-24-94
309-015-0040
Accounting and Record
Keeping
(1) Records retention. The provider
shall maintain, for a period of not less than three years following the date of
submission of the annual Medicaid cost report to the Medicaid Intermediary, financial
and statistical records of the period covered by such statement which are accurate
and in sufficient detail to substantiate the cost data reported. If there are audit
issues, the records shall be maintained for three years after the final audit settlement.
The records shall be maintained in a condition that can be audited for compliance
with generally accepted accounting principles and provisions of these rules. Failure
to maintain records in such condition shall result in disallowance of costs.
(2) Documentation of allowable
costs. Expenses reported as allowable costs must be adequately documented in the
financial records of the provider or they shall be disallowed.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89
309-015-0045
Filing of Annual Medicaid
Cost Report
(1) Timing of report. The provider
shall file annually with the Medicaid Intermediary, an annual Medicaid cost report
covering actual costs based on the latest fiscal period of operation of the facility.
If the provider has separate cost entities or distinct programs, an annual Medicaid
cost report shall be filed for each entity. A Medicaid cost report will be filed
for less than an annual period only when necessitated by facilities terminating
their agreement with the Division, or by a change in ownership, or by a change in
fiscal period. The provider is to use the same fiscal period for the Medicaid cost
report as that used for the Medicare cost report and the federal tax return. The
Medicaid cost report is due within 90 days of the end of the normal fiscal period,
change of ownership, or withdrawal from the program except when Medicare grants
an extension of the Medicare cost report (upon which the Medicaid cost report relies).
In that case, the due date for the Medicaid cost report may be extended by the Medicaid
Intermediary for the same number of days as the due date for the Medicare cost report.
(2) Contents of report. The
annual Medicaid cost report is a uniform cost report containing an itemized list
of allowable costs to be used by all providers. It shall report the hospital’s
actual financial data and be completed in accordance with instructions provided
by the Medicaid intermediary.
(3) Application of Medicare
principles of reimbursement. Providers filing annual Medicaid cost reports with
the Medicaid Intermediary shall apply Medicare principles of reimbursement.
(4) Signature. Each required
annual Medicaid cost report shall be signed by the individual who normally signs
the provider’s federal income tax return or other reports. If the report is
prepared by someone other than an employee of the provider, the individual preparing
the report shall also sign and indicate his or her status with the provider.
(5) Improperly completed reports.
The Medicaid Intermediary shall return improperly completed or incomplete annual
Medicaid cost reports to the provider for proper completion. All providers shall
return corrected or completed reports to the Division within 30 days or become subject
to the same penalty as for failure to submit the cost statement.
(6) Reduction of interim per
diem rate — Late reports. If the original submission of the Medicaid cost
report is not made within the required 90-day time period or extended period (see
section (1) of this rule), the interim per diem rate then in effect will be reduced
to 80 percent of the hospital’s current interim per diem rate or the rate
established from the last audited or desk reviewed cost statement, whichever is
lower. This rate will remain in effect until submission of the Medicaid cost report.
(7) Late-billed services. If
a hospital bills for services provided during a fiscal period for which the hospital
has submitted an annual Medicaid cost report, the days which are late-billed may
be included in the hospital’s next fiscal period.
(8) False reports. If a provider
knowingly, or with reason to know, files a report containing false information,
such action constitutes cause for termination of its agreement with the Division.
Providers filing false reports may be referred for prosecution under applicable
statutes (see OAR 309-015-0052).
(9) Maintenance of report. The
Medicaid Intermediary shall maintain each required annual Medicaid cost report submitted
by a provider for three years following the date of submission. In the event there
are audit questions, the cost statement shall be maintained for three years after
the final audit settlement.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89
309-015-0050
Auditing
(1) Desk review of annual Medicaid
cost report. The Medicaid intermediary will analyze by desk review each annual Medicaid
cost report after it has been properly completed and filed.
(2) Scope of desk review. The
scope of the desk review will verify, to the extent possible:
(a) That the provider has properly
included its allowable costs on the annual Medicaid cost report on the basis of
generally accepted accounting principles and the provisions of these rules;
(b) That the provider has properly
applied the cost finding method specified by the Medicaid Intermediary to its allowable
costs determined in subsection (a) of this section; and
(c) Whether or not the analysis
indicates that further auditing of the provider’s financial and statistical
records is needed.
(3) Allowable costs. The costs
considered allowable may include part or all of the following (worksheet form numbers
are correct as of the effective date of this rule):
(a) The costs stated as final
values on Worksheet B, HCFA-2552, Cost Allocation for General Services Costs;
(b) Physician costs as determined
by completing Worksheet A-8-2, HCFA-2552;
(c) Return on equity as determined
by completing the applicable portions of Worksheet F, HCFA-2552.
(4) Ownership changes. Payments
to providers shall not be increased, solely as a result of a change of ownership,
in excess of the increase which would result from applying Section 1861(v)(1)(O)
of the Social Security Act as applied to owners of record on or after July 18, 1984.
(5) Field audit. All filed annual
Medicaid cost reports are subject to a field audit.
(6) Scope of field audit. The
scope of the field audit will, at a minimum, be sufficiently comprehensive to verify
that in all material respects:
(a) Generally accepted accounting
principles and the provisions of these rules have been adhered to;
(b) Reported data is in agreement
with supporting records; and
(c) The report is reconcilable
to the appropriate Medicare report, federal tax return, and payroll tax reports.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 10-1984(Temp), f. &
ef. 12-21-84; MHD 3-1985, f. & ef. 2-25-85; MHD 7-1987, f. & ef. 12-30-87;
MHD 6-1989, f. & cert. ef. 11-17-89; MHD 2-1994, f. & cert. ef. 2-24-94
309-015-0052
Provider Sanctions
(1) Basis for sanctioning. The
Division will follow the Division of Medical Assistance Program rules OAR 410-120-0000
through 410-120-1980 and Section 1902 of the Social Security Act for provider sanctions.
The basis for sanctioning will include:
(a) Criminal convictions;
(b) Exclusion, by the Secretary
of Health and Human Services, from participation in the Medicare program;
(c) Not meeting the federal
regulatory requirements for services in an institution for mental diseases or a
psychiatric hospital as set forth at 42 CFR 435.1009 and 42 CFR 441, Subparts C and D;
(d) Having deficiencies which
immediately jeopardize, or may jeopardize, the health and safety of patients;
(e) Abuse and misutilization,
as described in OAR 410-120-0000 through 410-120-1980;
(f) Termination:
(A) From another governmental
health/medical program;
(B) For failure to repay identified
overpayments; or
(C) Due to commission, by a
provider formerly suspended by the Division, of additional abuse or misutilization.
(2) Sanctions. The following
sanctions may be imposed on a provider by the Division, based on grounds specified
in this rule and may include:
(a) Termination from participation
in Oregon’s Medical Assistance Program and possible initiation of appropriate
civil or criminal proceedings;
(b) Suspension from participation
in Oregon’s Medicaid Assistance Program;
(c) Suspension or withholding
of payments to a provider;
(d) Required attendance at provider
education sessions.
(3) Notice to providers. The
Division will notify a deficient provider of action the Division plans to take at
least 15 days prior to commencement of the action; the notification will include
an explanation of the provider’s right to appeal the proposed action (see
OAR 309-015-0055).
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 6-1989, f. &
cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef. 10-15-90; MHD 2-1994, f. &
cert. ef. 2-24-94
309-015-0055
Appeals
(1) Rate appeals. A letter will
be sent notifying the provider of the interim per diem rate, the year-end settlement
rate, or the final settlement rate. A provider shall notify the Division in writing
within 15 days of receipt of the letter if the provider wishes to appeal the rate.
Letters of appeal must be postmarked within the 15-day limit and addressed to the
Assistant Administrator, Administrative Services (the Medicaid Intermediary).
(2) The Medicaid Intermediary
will forward all rate appeals to the Manager of the Division’s Audit Section
for initial consideration. If no resolution is forthcoming, the provider will be
given an opportunity for administrative review or a contested case hearing as outlined
in OAR 410-120-1400 through 410-120-1600, except that final orders shall be issued
by the Administrator of the Division.
(3) Monetary recovery, sanctions,
or other appeals. A provider may appeal the Division’s proposed action by
letter within the same 15-day period as allowed for rate appeals above; address
the letter to the Assistant Administrator, Administrative Services (the Medicaid
Intermediary).
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 17-1983(Temp), f.
9-30-83, ef. 10-1-83; MHD 21-1983, f. & ef. 12-5-83; MHD 7-1987, f. & ef.
12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89; MHD 12-1990, f. & cert. ef.
10-15-90; MHD 2-1994, f. & cert. ef. 2-24-94
309-015-0060
Emergency Services in
Non-Participating Hospitals
Reimbursable services. Emergency
services provided in licensed psychiatric hospitals not participating in Medicaid
will be reimbursed if the Division determines they meet federal requirements for
Medicare reimbursement of emergency services as outlined in Subpart G, Part 424 of the Medicare regulations.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: MHD 7-1987, f. &
ef. 12-30-87; MHD 6-1989, f. & cert. ef. 11-17-89; MHD 2-1994, f. & cert.
ef. 2-24-94

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