OAR 410-125-0210: Third Party Resources and Reimbursement

(1) The Division of Medical Assistance Programs (Division) establishes maximum allowable reimbursements for all services. When clients have other third party payers, the payment made by that payer is deducted from the Division’s maximum allowable payment. (2) The Division will not make any additional reimbursement when a third party pays an amount equal to or greater than the Division’s reimbursement. The Division will not make any additional reimbursement when a third party pays 100 percent of the billed charges, except when Medicare Part A is the primary payer. (3) When Medicare is Primary: (a) The Division’s calculates the reimbursement for these claims in the same manner as described in the Inpatient and Outpatient Rates Calculations Sections above; (b) Payment is the Division allowable payment, less the Medicare payment, up to the amount of the deductible and/or coinsurance due. For clients who are Qualified Medicare Beneficiaries the Division does not make any reimbursement for a service that is not covered by Medicare. For clients who are Qualified Medicare/Medicaid Beneficiaries Division payment is the Division’s allowable, less the Part A payment up to the amount of the deductible due for services by either Medicare or Medicaid. (4) When Medicare is Secondary: (a) An individual admitted to a hospital may have Medicare Part B, but not Part A. The Division calculates the reimbursement for these claims in the same manner as described in the Inpatient Rates Calculations section above. Payment is the Division’s allowable payment, less the Medicare Part B payment; (b) An individual receiving services in the outpatient setting may have most services covered by Medicare Part B. The Division payment is the Division’s allowable payment, less the Part B payment, up to the amount of the coinsurance and deductible due. For services provided in the outpatient setting which are not covered by Medicare, (for example, Take Home Drugs), the Division payment is the Division’s allowable payment as calculated in the Outpatient Rates Calculation section above; (c) Most Medicare-Medicaid clients have Medicare Part A, Part B, and full Medicaid coverage. The Division refers to these clients as Qualified Medicare-Medicaid Beneficiaries (QMM). However, a few individuals have Medicare coverage and only limited additional coverage through Medicaid. the Division refers to these clients as Qualified Medicare Beneficiaries (QMB). For QMB clients, the Division does not make reimbursement for a service that is a not covered service for Medicare. (d) Clients who are Qualified Medicare-Medicaid Beneficiaries will have coverage for services that are not covered by Medicare if those services are covered by the Division. (5) For clients with Physician Care Organization (PCO) or Prepaid Health Plan (PHP) Coverage, Division payment is limited to those services that are not the responsibility of the PCO or PHP. Payment is made at Division rates. (6) Other Insurance: (a) The Division pays the maximum allowable payment as described in the Inpatient and Outpatient Rates Calculations, less any third party payments; (b) The Division will not make additional reimbursements when a third party payor (other than Medicare) pays an amount equal to or greater than the Division reimbursement, or 100 percent of billed charges. (7) Medically Needy with Spend-Down. Reimbursement is the Division’s maximum allowable payment for covered services less the amount of the spend-down due.