OAR 410-125-0181: Non-Contiguous and Contiguous Area Out-of-State Hospitals — Outpatient Services

Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Contiguous area hospitals are out-of-state hospitals located less than 75 miles outside the Oregon border. Unless such hospitals have an agreement with the Agency of Medical Assistance Programs (Agency) regarding reimbursement for specialized services, these hospitals shall be reimbursed as follows: (1) Laboratory, diagnostic and therapeutic radiology, nuclear medicine, CT scans, MRI services, other imaging services, and maternity case management services shall be reimbursed under an Agency fee schedule. (2) All other outpatient services shall be reimbursed at 50 percent of billed charges. There is no cost settlement. (3) Notwithstanding subsection (2) of this rule, this subsection becomes effective for dates of service on and after January 1, 2025. Unless such hospitals have an agreement with the Agency regarding reimbursement for specialized services, these hospitals shall be reimbursed as follows: (a) Out-of-state contiguous and non-contiguous hospitals are reimbursed at an APC methodology as outlined in 3(b)-(f) (b) Out-of-state contiguous and non-contiguous reimbursement methodology for hospitals shall be calculated using the wage index and outlier parameters set at the 50th percentile of Oregon hospitals. (c) The Agency shall grandfather a reimbursement of 50 percent of the 2024 hospital-specific charge master in lieu of the calculation in section 3(b) of this rule, if such payment is requested by the hospital. Supporting documentation shall be required for this process. (d) Clinical laboratory services shall be reimbursed under an Agency fee schedule; (e) There shall be no cost settlement for out-of-state contiguous and non-contiguous outpatient services. (f) The reimbursement for out-of-state contiguous and non-contiguous hospitals will be 80% of Medicare. (4) The National Drug Code (NDC) must be included on the electronic (837I) and paper (UB 04) claims for physician administered drug codes required by the Deficit Reduction Act of 2005.