ORS 414.743¹
Payment to noncontracting hospital by fully capitated health plan
  • rules

(1) As used in this section, "fully capitated health plan" means an organization that contracts with the Department of Human Services on a prepaid capitated basis under ORS 414.725 (Prepaid managed care health services contracts) to provide an adequate network of providers to ensure that all health services described in ORS 414.705 (Definitions for ORS 414.705 to 414.750) are reasonably accessible to enrollees.

(2) A fully capitated health plan that does not have a contract with a hospital to provide inpatient or outpatient hospital 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) must pay for hospital services at 80 percent of the Medicare rate for the noncontracting hospital.

(3) A hospital that does not have a contract with a fully capitated health plan to provide inpatient or outpatient hospital 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) must accept as payment in full the rates described in subsection (2) of this section.

(4) This section does not apply to type A and type B hospitals, as described in ORS 442.470 (Definitions for ORS 442.470 to 442.507), and rural critical access hospitals, as defined in ORS 315.613 (Credit available to persons providing rural medical care and affiliated with certain rural hospitals).

(5) The Department of Human Services shall adopt rules to implement and administer this section. [Subsection (1) of 2003 Edition enacted as 2003 c.735 §16(1); subsections (2) to (5) of 2003 Edition enacted as 2003 c.735 §16(2) to (5) and 2003 c.810 §12(1) to (4); 2007 c.886 §1]

Note: The amendments to 414.743 (Payment to noncontracting hospital by fully capitated health plan) by section 2, chapter 886, Oregon Laws 2007, become operative January 2, 2010. See section 3, chapter 886, Oregon Laws 2007. The text that is operative on and after January 2, 2010, is set forth for the user’s convenience.

414.743 (Payment to noncontracting hospital by fully capitated health plan). (1) As used in this section, "fully capitated health plan" means an organization that contracts with the Department of Human Services on a prepaid capitated basis under ORS 414.725 (Prepaid managed care health services contracts) to provide an adequate network of providers to ensure that all health services described in ORS 414.705 (Definitions for ORS 414.705 to 414.750) are reasonably accessible to enrollees.

(2) A fully capitated health plan that does not have a contract with a hospital to provide inpatient or outpatient hospital 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) must pay for hospital services as follows:

(a) For inpatient hospital services, based on the capitation rates developed for the budget period, at the level of the statewide average unit cost, multiplied by the geographic factor, the payment discount factor and an adjustment factor of 0.925.

(b) For outpatient hospital services, based on the capitation rates developed for the budget period, at the level of charges multiplied by the statewide average cost-to-charge ratio, the geographic factor, the payment discount factor and an adjustment factor of 0.925.

(3) A hospital that does not have a contract with a fully capitated health plan to provide inpatient or outpatient hospital 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) must accept as payment in full for hospital services, rates:

(a) For inpatient hospital services, based on the capitation rates developed for the budget period, at the level of the statewide average unit cost, multiplied by the geographic factor, the payment discount factor and an adjustment factor of 0.925.

(b) For outpatient hospital services, based on the capitation rates developed for the budget period, at the level of charges multiplied by the statewide average cost-to-charge ratio, the geographic factor, the payment discount factor and an adjustment factor of 0.925.

(4) This section does not apply to type A and type B hospitals, as described in ORS 442.470 (Definitions for ORS 442.470 to 442.507), and rural critical access hospitals, as defined in ORS 315.613 (Credit available to persons providing rural medical care and affiliated with certain rural hospitals).

(5) The Department of Human Services shall adopt rules to implement and administer this section.

Note: See note under 414.736 (Definitions).

1 Legislative Counsel Committee, CHAPTER 414—Medical Assistance, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­414.­html (2007) (last ac­cessed Feb. 12, 2009).
 
2 Legislative Counsel Committee, Annotations to the Oregon Revised Stat­utes, Cumulative Supplement - 2007, Chapter 414, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­414ano.­htm (2007) (last ac­cessed Feb. 12, 2009).
 
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.
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