2017 ORS 243.879¹
Reimbursement methodology for payment to hospitals

(1) A hospital that provides services or supplies under a benefit plan offered by the Oregon Educators Benefit Board shall be reimbursed using the methodology prescribed by the Oregon Health Authority under ORS 442.392 (Uniform payment methodology for hospital and ambulatory surgical center services) and may not be reimbursed for each service or supply provided.

(2) This section applies to hospital payments made by a carrier under a contract with the board and to hospital payments made under a self-insurance program administered by a third party administrator on behalf of the board.

(3) This section does not apply to reimbursements paid by a carrier or third party administrator to a hospital that is not subject to the methodology prescribed by the authority under ORS 442.392 (Uniform payment methodology for hospital and ambulatory surgical center services). [2011 c.418 §8]

Note: The amendments to 243.879 (Reimbursement methodology for payment to hospitals) by section 31, chapter 746, Oregon Laws 2017, apply to health benefit plans offered by the Oregon Educators Benefit Board for plan years beginning after July 1, 2019. See section 34, chapter 746, Oregon Laws 2017. The text that applies to plan years beginning after July 1, 2019, is set forth for the user’s convenience.

243.879 (Reimbursement methodology for payment to hospitals). (1) A carrier that contracts with the Oregon Educators Benefit Board to provide to eligible employees and their dependents a benefit plan that reimburses the cost of inpatient or outpatient hospital services or supplies shall reimburse a claim for the cost of a hospital service or supply that is covered by, or is similar to a service or supply that is covered by, the Medicare program in an amount that does not exceed:

(a) For claims submitted by in-network hospitals, 200 percent of the amount paid by Medicare for the service or supply; or

(b) For claims submitted by out-of-network hospitals, 185 percent of the amount paid by Medicare for the service or supply.

(2) A self-insurance program administered by a third party administrator that is offered by the board to eligible employees and their dependents and that reimburses the cost of inpatient or outpatient hospital services or supplies shall reimburse a claim for the cost of a hospital service or supply that is covered by, or is similar to a service or supply that is covered by, the Medicare program in an amount that does not exceed:

(a) For claims submitted by in-network hospitals, 200 percent of the amount paid by Medicare for the service or supply; or

(b) For claims submitted by out-of-network hospitals, 185 percent of the amount paid by Medicare for the service or supply.

(3) A provider who is reimbursed in accordance with subsection (1) or (2) of this section may not charge to or collect from the patient or a person who is financially responsible for the patient an amount in addition to the reimbursement paid under subsection (1) or (2) of this section other than cost sharing amounts authorized by the terms of the health benefit plan.

(4) If a carrier or third party administrator does not reimburse claims on a fee-for-service basis, the payment method used must take into account the limits specified in subsections (1) and (2) of this section. Such payment methods include, but are not limited to:

(a) Value-based payments;

(b) Capitation payments; and

(c) Bundled payments.

(5) This section does not apply to reimbursements paid by a carrier or third party administrator to:

(a) A type A or type B hospital as described in ORS 442.470 (Definitions for ORS 442.470 to 442.507);

(b) A rural critical access hospital as defined in ORS 315.613 (Credit available to persons providing rural medical care and affiliated with certain rural hospitals); or

(c) A hospital:

(A) Located in a county with a population of less than 70,000 on August 15, 2017;

(B) Classified as a sole community hospital by the Centers for Medicare and Medicaid Services; and

(C) With Medicare payments composing at least 40 percent of the hospital’s total annual patient revenue.

(6) This section does not require a health benefit plan offered by the board to reimburse claims using a fee-for-service payment method.

Note: See note under 243.860 (Definitions for ORS 243.860 to 243.886).

Chapter 243

Notes of Decisions

Effect of Public Employe Rela­tions Act is to modify authority of Personnel Division so that, while division retains responsibility for es­tab­lishing general job salary grades and classifica­tions, specific salary within each range which is paid to employe in public employe bargaining unit is subject to negotia­tion or arbitra­tion under terms of this chapter. AFSCME v. Executive Dept., 52 Or App 457, 628 P2d 1228 (1981), Sup Ct review denied

Provision of collective bargaining agree­ment giving present employes lateral transfer rights was valid under ORS 240.321 (Collective bargaining) and fact that its imple­menta­tion resulted in male succeeding female employe did not violate state af­firm­a­tive ac­tion statutes. State Executive Dept. v. OPEU, 91 Or App 124, 754 P2d 582 (1988)

Atty. Gen. Opinions

State agencies paying carpooling employes’ parking fees, (1974) Vol 36, p 1015

Law Review Cita­tions

51 OLR 23, 44 (1971)

1 Legislative Counsel Committee, CHAPTER 243—Public Employee Rights and Benefits, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ors243.­html (2017) (last ac­cessed Mar. 30, 2018).
 
2 Legislative Counsel Committee, Annotations to the Oregon Revised Stat­utes, Cumulative Supplement - 2017, Chapter 243, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ano243.­html (2017) (last ac­cessed Mar. 30, 2018).
 
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.