Determination of benchmarks for setting per capita rates
(1) The Health Services Commission shall retain an actuary to determine the benchmark for setting per capita rates necessary to reimburse prepaid managed care health services organizations and fee-for-service providers for the cost of providing health services under ORS 414.705 (Definitions for ORS 414.705 to 414.750) to 414.750 (Authority of Legislative Assembly to authorize services for other persons).
(2) The actuary retained by the commission shall use the following information to determine the benchmark for setting per capita rates:
(a) For hospital services, the most recently available Medicare cost reports for Oregon hospitals;
(b) For services of physicians licensed under ORS chapter 677 and other health professionals using procedure codes, the Medicare Resource Based Relative Value system conversion rates for Oregon;
(c) For prescription drugs, the most recent payment methodologies in the fee-for-service payment system for the Oregon Health Plan;
(d) For durable medical equipment and supplies, 80 percent of the Medicare allowable charge for purchases and rentals;
(e) For dental services, the most recent payment rates obtained from dental care organization encounter data; and
(f) For all other services not listed in paragraphs (a) to (e) of this subsection:
(A) The Medicare maximum allowable charge, if available; or
(B) The most recent payment rates obtained from the data available under subsection (3) of this section.
(3) The actuary shall use the most current encounter data and the most current fee-for-service data that is available, reasonable trends for utilization and cost changes to the midpoint of the next biennium, appropriate differences in utilization and cost based on geography, state and federal mandates and other factors that, in the professional judgment of the actuary, are relevant to the fair and reasonable estimation of costs. The Department of Human Services shall provide the actuary with the data and information in the possession of the department or contractors of the department reasonably necessary to develop a benchmark for setting per capita rates.
(4) The commission shall report the benchmark per capita rates developed under this section to the Director of the Oregon Department of Administrative Services, the Director of Human Services and the Legislative Fiscal Officer no later than August 1 of every even-numbered year.
(5) The Department of Human Services shall retain an actuary to determine:
(a) Per capita rates for health services that the department shall use to develop the department’s proposed biennial budget; and
(b) Capitation rates to reimburse physician care organizations for the cost of providing health services under ORS 414.705 (Definitions for ORS 414.705 to 414.750) to 414.750 (Authority of Legislative Assembly to authorize services for other persons) using the same methodologies used to develop capitation rates for fully capitated health plans. The rates may not advantage or disadvantage fully capitated health plans for similar services.
(6) The Department of Human Services shall submit to the Legislative Assembly no later than February 1 of every odd-numbered year a report comparing the per capita rates for health services on which the proposed budget of the department is based with the rates developed by the actuary retained by the Health Services Commission. If the rates differ, the department shall disclose, by provider categories described in subsection (2) of this section, the amount of and reason for each variance. [2003 c.810 §9]
Note: See note under 414.736 (Definitions).
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