Bill Text: OR HB2377 | 2011 | Regular Session | Introduced
Bill Title: Relating to Medicaid reimbursement of type B hospitals.
Spectrum: Unknown
Status: (Failed) 2011-06-30 - In committee upon adjournment. [HB2377 Detail]
Download: Oregon-2011-HB2377-Introduced.html
76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 949
House Bill 2377
Ordered printed by the Speaker pursuant to House Rule 12.00A (5).
Presession filed (at the request of House Interim Committee on
Health Care)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Modifies definition of 'type B hospital' for purposes of
Medicaid reimbursement rates to require hospital to have
five-year average operating margin of five percent or less.
Requires Oregon Health Authority to prescribe methodology by rule
for determining five-year average operating margin.
A BILL FOR AN ACT
Relating to Medicaid reimbursement of type B hospitals; creating
new provisions; and amending ORS 414.025, 414.727, 414.728 and
414.743.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 414.025, as amended by section 1, chapter 73,
Oregon Laws 2010, is amended to read:
414.025. As used in this chapter, unless the context or a
specially applicable statutory definition requires otherwise:
(1) 'Category of aid' means assistance provided by the Oregon
Supplemental Income Program, aid granted under ORS 412.001 to
412.069 and 418.647 or federal Supplemental Security Income
payments.
(2) 'Categorically needy' means, insofar as funds are available
for the category, a person who is a resident of this state and
who:
(a) Is receiving a category of aid.
(b) Would be eligible for a category of aid but is not
receiving a category of aid.
(c) Is in a medical facility and, if the person left such
facility, would be eligible for a category of aid.
(d) Is under the age of 21 years and would be a dependent child
as defined in ORS 412.001 except for age and regular attendance
in school or in a course of professional or technical training.
(e)(A) Is a caretaker relative, as defined in ORS 412.001, who
cares for a child who would be a dependent child except for age
and regular attendance in school or in a course of professional
or technical training; or
(B) Is the spouse of the caretaker relative.
(f) Is under the age of 21 years and:
(A) Is in a foster family home or licensed child-caring agency
or institution and is one for whom a public agency of this state
is assuming financial responsibility, in whole or in part; or
(B) Is 18 years of age or older, is one for whom federal
financial participation is available under Title XIX or XXI of
the federal Social Security Act and who met the criteria in
subparagraph (A) of this paragraph immediately prior to the
person's 18th birthday.
(g) Is a spouse of an individual receiving a category of aid
and who is living with the recipient of a category of aid, whose
needs and income are taken into account in determining the cash
needs of the recipient of a category of aid, and who is
determined by the Department of Human Services to be essential to
the well-being of the recipient of a category of aid.
(h) Is a caretaker relative as defined in ORS 412.001 who cares
for a dependent child receiving aid granted under ORS 412.001 to
412.069 and 418.647 or is the spouse of the caretaker relative.
(i) Is under the age of 21 years, is in a youth care center and
is one for whom a public agency of this state is assuming
financial responsibility, in whole or in part.
(j) Is under the age of 21 years and is in an intermediate care
facility which includes institutions for persons with mental
retardation.
(k) Is under the age of 22 years and is in a psychiatric
hospital.
(L) Is under the age of 21 years and is in an independent
living situation with all or part of the maintenance cost paid by
the Department of Human Services.
(m) Is a member of a family that received aid in the preceding
month under ORS 412.006 or 412.014 and became ineligible for aid
due to increased hours of or increased income from employment. As
long as the member of the family is employed, such families will
continue to be eligible for medical assistance for a period of at
least six calendar months beginning with the month in which such
family became ineligible for assistance due to increased hours of
employment or increased earnings.
(n) Is an adopted person under 21 years of age for whom a
public agency is assuming financial responsibility in whole or in
part.
(o) Is an individual or is a member of a group who is required
by federal law to be included in the state's medical assistance
program in order for that program to qualify for federal funds.
(p) Is an individual or member of a group who, subject to the
rules of the department, may optionally be included in the
state's medical assistance program under federal law and
regulations concerning the availability of federal funds for the
expenses of that individual or group.
(q) Is a pregnant woman who would be eligible for aid granted
under ORS 412.001 to 412.069 and 418.647, whether or not the
woman is eligible for cash assistance.
(r) Except as otherwise provided in this section, is a pregnant
woman or child for whom federal financial participation is
available under Title XIX or XXI of the federal Social Security
Act.
(s) Is not otherwise categorically needy and is not eligible
for care under Title XVIII of the federal Social Security Act or
is not a full-time student in a post-secondary education program
as defined by the Department of Human Services by rule, but whose
family income is less than the federal poverty level and whose
family investments and savings equal less than the investments
and savings limit established by the department by rule.
(t) Would be eligible for a category of aid but for the receipt
of qualified long term care insurance benefits under a policy or
certificate issued on or after January 1, 2008. As used in this
paragraph, 'qualified long term care insurance' means a policy or
certificate of insurance as defined in ORS 743.652 (6).
(u) Is eligible for the Health Care for All Oregon Children
program established in ORS 414.231.
(3) 'Income' has the meaning given that term in ORS 411.704.
(4) 'Investments and savings' means cash, securities as defined
in ORS 59.015, negotiable instruments as defined in ORS 73.0104
and such similar investments or savings as the Department of
Human Services may establish by rule that are available to the
applicant or recipient to contribute toward meeting the needs of
the applicant or recipient.
(5) 'Medical assistance' means so much of the following medical
and remedial care and services as may be prescribed by the Oregon
Health Authority according to the standards established pursuant
to ORS 413.032, including payments made for services provided
under an insurance or other contractual arrangement and money
paid directly to the recipient for the purchase of medical care:
(a) Inpatient hospital services, other than services in an
institution for mental diseases;
(b) Outpatient hospital services;
(c) Other laboratory and X-ray services;
(d) Skilled nursing facility services, other than services in
an institution for mental diseases;
(e) Physicians' services, whether furnished in the office, the
patient's home, a hospital, a skilled nursing facility or
elsewhere;
(f) Medical care, or any other type of remedial care recognized
under state law, furnished by licensed practitioners within the
scope of their practice as defined by state law;
(g) Home health care services;
(h) Private duty nursing services;
(i) Clinic services;
(j) Dental services;
(k) Physical therapy and related services;
(L) Prescribed drugs, including those dispensed and
administered as provided under ORS chapter 689;
(m) Dentures and prosthetic devices; and eyeglasses prescribed
by a physician skilled in diseases of the eye or by an
optometrist, whichever the individual may select;
(n) Other diagnostic, screening, preventive and rehabilitative
services;
(o) Inpatient hospital services, skilled nursing facility
services and intermediate care facility services for individuals
65 years of age or over in an institution for mental diseases;
(p) Any other medical care, and any other type of remedial care
recognized under state law;
(q) Periodic screening and diagnosis of individuals under the
age of 21 years to ascertain their physical or mental
impairments, and such health care, treatment and other measures
to correct or ameliorate impairments and chronic conditions
discovered thereby;
(r) Inpatient hospital services for individuals under 22 years
of age in an institution for mental diseases; and
(s) Hospice services.
(6) 'Medical assistance' includes any care or services for any
individual who is a patient in a medical institution or any care
or services for any individual who has attained 65 years of age
or is under 22 years of age, and who is a patient in a private or
public institution for mental diseases. 'Medical assistance '
includes 'health services' as defined in ORS 414.705. 'Medical
assistance' does not include care or services for an inmate in a
nonmedical public institution.
(7) 'Medically needy' means a person who is a resident of this
state and who is considered eligible under federal law for
medically needy assistance.
(8) 'Resources' has the meaning given that term in ORS 411.704.
For eligibility purposes, 'resources' does not include charitable
contributions raised by a community to assist with medical
expenses.
{ + (9) 'Rural critical access hospital' has the meaning
given that term in ORS 315.613.
(10) 'Type A hospital' means a type A hospital as described in
ORS 442.470.
(11) 'Type B hospital' means a hospital that:
(a) Is small and rural according to standards established by
the Office of Rural Health;
(b) Was not designated by the federal government as a rural
referral hospital before January 1, 1989; and
(c) Has a five-year average operating margin of five percent or
less according to methodologies prescribed by the Oregon Health
Authority by rule. + }
SECTION 2. ORS 414.727 is amended to read:
414.727. (1) A prepaid managed care health services
organization, as defined in ORS 414.736, that contracts with the
Oregon Health Authority under ORS 414.725 (1) to provide prepaid
managed care health services, including hospital services, shall
reimburse type A and type B hospitals and rural critical access
hospitals { - , as described in ORS 442.470 and identified by
the Office of Rural Health as rural hospitals, - } fully for the
cost of covered services based on the cost-to-charge ratio used
for each hospital in setting the capitation rates paid to the
prepaid managed care health services organization for the
contract period.
(2) The authority shall base the capitation rates described in
subsection (1) of this section on the most recent audited
Medicare cost report for Oregon hospitals adjusted to reflect the
Medicaid mix of services.
(3) This section may not be construed to prohibit a prepaid
managed care health services organization and a hospital from
mutually agreeing to reimbursement other than the reimbursement
specified in subsection (1) of this section.
(4) Hospitals reimbursed under subsection (1) of this section
are not entitled to any additional reimbursement for services
provided.
SECTION 3. ORS 414.728 is amended to read:
414.728. For services provided to persons who are entitled to
receive medical assistance and whose medical assistance benefits
are not administered by a prepaid managed care health services
organization, as defined in ORS 414.736, the Oregon Health
Authority shall reimburse type A and type B hospitals and rural
critical access hospitals { - , as described in ORS 442.470 and
identified by the Office of Rural Health as rural hospitals, - }
fully for the cost of covered services based on the most recent
audited Medicare cost report for Oregon hospitals adjusted to
reflect the Medicaid mix of services.
SECTION 4. ORS 414.743 is amended to read:
414.743. (1) 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 to 414.750 must, using a
Medicare payment methodology, reimburse the noncontracting
hospital for services provided to an enrollee of the plan 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 two percentage points less than the
percentage of Medicare cost used by the authority in calculating
the base hospital capitation payment to the plan, excluding any
supplemental payments.
(2) 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 to 414.750 must accept as payment in
full for hospital services the rates described in subsection (1)
of this section.
(3) 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 315.613 - } .
(4) The Oregon Health Authority shall adopt rules to implement
and administer this section.
SECTION 5. { + The amendments to ORS 414.025, 414.727, 414.728
and 414.743 by sections 1 to 4 of this 2011 Act apply to
contracts or agreements entered into by the Oregon Health
Authority or the Department of Human Services with hospitals on
or after the effective date of this 2011 Act. + }
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