OAR 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.