OAR 943-120-0350: Payments and Overpayments

(1) When an individual’s health care services or item is reimbursed by the Medical Assistance Program, either through a CCO, MCO or the Authority, the provider shall comply with the payment requirements pursuant to OAR chapter 410 or established under contract with that CCO or MCO. (2) All other covered services and items provided to eligible individuals not part of the Medical Assistance Program shall be: (a) Within the program-specific contract in effect on the date of service; (b) Based on program-specific or contract fee schedules or other reimbursement methods; or (c) For services that are paid for by the Authority, on behalf of a county, authorized by and at the request of a county, provider reimbursement shall include county service authorization information. (3) The Authority shall pay for services or items for hospitals and ambulatory surgical center services using: (a) The most recent Medicare payment methodologies established by the Centers for Medicare and Medicaid Services, or similar payment methodologies; or (b) An alternative payment methodology. (4) For purposes of this rule, “Alternative payment methodology” means a payment other than a fee-for-services payment, used by health plans as compensation for the provision of integrated and coordinated health care and services. “Alternative payment methodology” includes, but is not limited to: (a) Shared savings arrangements; (b) Bundled payments; (c) Payments based on episodes; (d) Pay for performance; or (e) Capitation. (5) The reimbursement methods in these rules are described in greater detail for the Medical Assistance Program in chapter 410 Division 125, the Public Employees’ Benefit Board, chapter 101 and the Oregon Educators Benefits Board, chapter 111 program rules.