ORS 414.743 Payment to noncontracting hospital by coordinated care organization; rules

Except as provided in subsection (2) of this section, a coordinated care organization that does not have a contract with a hospital to provide inpatient or outpatient hospital services under ORS 414.591, 414.631 and 414.688 to 414.745 must, using Medicare payment methodology, reimburse the noncontracting hospital for services provided to a member of the organization at a rate no less than a percentage of the Medicare reimbursement rate for those services. The percentage of the Medicare reimbursement rate that is used to determine the reimbursement rate under this subsection is equal to four percentage points less than the percentage of Medicare cost used by the Oregon Health Authority in calculating the base hospital capitation payment to the organization, excluding any supplemental payments.

If a coordinated care organization does not have a contract with a hospital, and the hospital provides less than 10 percent of the hospital admissions and outpatient hospital services to members of the organization, the percentage of the Medicare reimbursement rate that is used to determine the reimbursement rate under subsection (1) of this section is equal to two percentage points less than the percentage of Medicare cost used by the Oregon Health Authority in calculating the base hospital capitation payment to the organization, excluding any supplemental payments.

This subsection is not intended to discourage a coordinated care organization and a hospital from entering into a contract and is intended to apply to hospitals that provide primarily, but not exclusively, specialty and emergency care to members of the organization.

A hospital that does not have a contract with a coordinated care organization to provide inpatient or outpatient hospital services under ORS 414.591, 414.631 and 414.688 to 414.745 must accept as payment in full for hospital services the rates described in subsections (1) and (2) of this section.

This section does not apply to type A and type B hospitals, as described in ORS 442.470, and rural critical access hospitals, as defined in ORS 442.470.

The Oregon Health Authority shall adopt rules to implement and administer this section.