OAR 410-125-0155: Upper Limits on Payment of Hospital Claims

(1) Supplemental payments: (a) Private Hospital Supplemental Payments: (A) From the private Upper Payment Limit (UPL) gap, payments shall be made to all private Diagnosis Related Groups (DRG) hospitals in the form of a per discharge payment applied to hospital specific Medicaid fee-for-service discharges from the quarter preceding the month of the payment; (B) This payment will be equal to one quarter of the gap amount divided by the total private DRG hospital Medicaid fee-for-service discharges from the quarter proceeding the month of payment; (C) The supplemental payments for Private Hospitals will not exceed the UPL for inpatient hospital services. (b) Non-State Government Owned Hospital Supplemental Payments: (A) From the non-state government owned hospital upper payment limit gap, payments shall be made to all non-state government owned DRG hospitals in the form of a per discharge payment applied to hospital specific Medicaid fee-for-service discharges from the quarter preceding the month of the payment; (B) This payment will be equal to one quarter of the gap amount divided by the total non-state government owned DRG hospital Medicaid fee-for-service discharges from the quarter proceeding the month of payment; (C) The supplemental payments for non-state government owned Hospitals will not exceed the UPL for inpatient hospital services. (2) For Type A, Type B and Critical Access Hospitals, reimbursement shall be limited to the lesser of allowable costs or billed charges. This limitation shame be applied separately to inpatient and outpatient services. (3) Payments will not exceed final approved plan: (a) Total reimbursements to a state-operated facility made during the Division of Medical Assistance Program (Division) fiscal year (July 1 through June 30) may not exceed any limit imposed under federal law in the final approved plan; (b) Total aggregate inpatient and outpatient reimbursements to all hospitals made during the Division’s fiscal year (July 1 through June 30) may not exceed any limit imposed under federal law in the final approved plan.