2017 ORS 414.743¹
Payment to noncontracting hospital by coordinated care organization
  • rules

(1) 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 414.631 (Mandatory enrollment in coordinated care organization), 414.651 (Coordinated care organization contracts) and 414.688 (Commission established) to 414.745 (Liability of health care providers and plans) 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.

(2)(a) 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.

(b) 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.

(3) A hospital that does not have a contract with a coordinated care organization to provide inpatient or outpatient hospital services under ORS 414.631 (Mandatory enrollment in coordinated care organization), 414.651 (Coordinated care organization contracts) and 414.688 (Commission established) to 414.745 (Liability of health care providers and plans) must accept as payment in full for hospital services the rates described in subsections (1) and (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 442.470 (Definitions for ORS 442.470 to 442.507).

(5) The Oregon Health Authority 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 §§1,2; 2009 c.595 §§337,338; 2009 c.886 §§4,5; 2011 c.602 §§47,71; 2015 c.27 §46; 2017 c.718 §8]

Law Review Cita­tions

72 OLR 47 (1993)

1 Legislative Counsel Committee, CHAPTER 414—Medical Assistance, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ors414.­html (2017) (last ac­cessed Mar. 30, 2018).
 
2 Legislative Counsel Committee, Annotations to the Oregon Revised Stat­utes, Cumulative Supplement - 2017, Chapter 414, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ano414.­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.