Or. Admin. Code § 101-080-0020

Current through Register Vol. 64, No. 1, January 1, 2025

Section 101-080-0020 - Exempt Hospitals

(1) As specified in ORS 243.256, these payment limits do not apply to reimbursements paid by a carrier or third-party administrator to:

(a) Type A or type B hospitals (defined in ORS 442.470);

(b) Rural critical access hospitals (defined in ORS 315.613); or

(c) Hospitals that are located in a county with a population of less than 70,000 on August 15, 2017, classified as a sole community hospital by the Centers for Medicare and Medicaid Services, and have Medicare payments composing at least 40 percent of the hospital's total annual patient revenue.

(2)

(a) Total annual patient revenue for a hospital will be calculated using the Allowed Amount for all inpatient and outpatient claim records in the state's All Payer All Claims (APAC) database for that hospital in a calendar year, and

(b) Total Medicare payments to a hospital will be calculated using the Allowed Amount for all inpatient and outpatient claim records paid by Medicare in the APAC for that hospital in a calendar year.

(3) PEBB will review the calculation under section (2) of this rule at least every three years using the most recent available data in APAC.

Or. Admin. Code § 101-080-0020

PEBB 4-2019, adopt filed 10/21/2019, effective 10/22/2019; PEBB 8-2020, amend filed 12/22/2020, effective 12/22/2020

Statutory/Other Authority: ORS 243.061 to ORS 243.302 & ORS 243.125(1)

Statutes/Other Implemented: ORS 243.256