OAR 101-080-0010: Hospital Payments

(1) Except as provided in section (10), the maximum reimbursement amount for each claim subject to ORS 243.256 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 actual reimbursement amount for each claim subject to ORS 243.256 and these rules shall be based on the lesser of billed charges, the carrier's contracted rate for the provider, or the maximum reimbursement amount established in ORS 243.256 and these rules. (3) The carrier shall determine the PEBB member’s cost sharing based on the actual reimbursement amount as determined in section (2) above. (4) Any actions taken by the Centers for Medicare and Medicaid Services (CMS) that result in retroactive adjustment of the maximum reimbursement amount for an inpatient or outpatient hospital service or supply shall not result in retroactive increases to member cost sharing. (5) The following payments shall not be included under ORS 243.256(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 (d) services or supplies provided at CMS designated children's hospitals that are not reimbursed via the Inpatient Prospective Payment System (IPPS). (6) If a third-party administrator of a self-insured plan provides total fee-for-service payments to an in-network hospital under ORS 243.256(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 PEBB. Moneys returned to PEBB under this rule will be deposited in the Public Employees’ Revolving Fund for purposes consistent with ORS 243.167. (7) If a fully-insured carrier provides total fee-for-service payments to an in-network hospital under ORS 243.256(1) or (2) that exceed twice the total payments at the Medicare rate for the plan year, the fully-insured carrier will provide PEBB a credit to fully-insured premium rates equivalent to this difference. (8) If a third-party administrator of a self-insured plan provides total fee-for-service payments to an out-of-network hospital under ORS 243.256(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 PEBB. Moneys returned to PEBB under this rule will be deposited in the Public Employees’ Revolving Fund for purposes consistent with ORS 243.167. (9) If a fully-insured carrier provides total fee-for-service payments to an out-of-network hospital under ORS 243.256(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 PEBB a credit to fully-insured premium rates equivalent to this difference. (10) 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 243.256 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 243.256. Such alternative payment methods must be reported to PEBB 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 243.256 the carrier or third-party administrator will return the difference to PEBB. Moneys returned to PEBB under this rule will be deposited in the Public Employees’ Revolving Fund for purposes consistent with ORS 243.167. (11) For purposes of this rule, the “Medicare rate” is the amount of reimbursement for a claim that would be paid as if The Centers for Medicare and Medicaid Services (CMS) reimbursed the claim. Therefore, calculation of the maximum reimbursement amount for outpatient services applies the Medicare Ambulatory Payment Classification (APC) or Hospital Outpatient Prospective Payment System (OPPS), and calculation of the maximum reimbursement amount for inpatient services applies the Inpatient Prospective Patient System (IPPS). Claims submitted for reimbursement must include all CMS required modifiers so that all rebates, incentives, or adjustments that would have applied if reimbursed by Medicare would also apply. The "Medicare rate" as defined in this rule is used to determine the maximum reimbursement amount for each claim subject to ORS 243.256 and these rules and in no way prohibits a carrier or third-party administrator from establishing contracted claims reimbursement rates that are lower than the maximum reimbursement amount. This includes contracted claims reimbursement rates informed by Medicare Advantage rates, so long as contacted rates do not exceed the maximum reimbursement established in ORS 243.256 and this rule. Furthermore, this includes capturing data fields on claims for services or supplies that are necessary to determine the Medicare rate for the service or supply to the extent needed to ensure that the actual reimbursement amount does not exceed the maximum reimbursement amount established in ORS 243.256 and this rule.