Or. Admin. Code § 410-125-0230

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

Section 410-125-0230 - Qualified Directed Payments

Qualified Directed Payments (QDP) are payments made by the Oregon Health Authority (Authority) to Coordinated Care Organizations (CCOs) from three Quality and Access pools for distinct provider classes as follows:

(i) Rural Type A and Type B hospitals,

(ii) Public Academic Health Centers and

(iii) DRG hospitals. Each provider class is defined in §438.6(c) Preprint forms approved by the U.S. Department of health and Human Services Centers for Medicare and Medicaid Services. QDPs are tied to inpatient and outpatient encounters with Medicaid and Children's Health Insurance Program (CHIP) members enrolled in Coordinated Care Organizations. However, the Authority does not make Qualified Directed Payments for encounters with members who received Citizenship Waived Medical (CWM) or CWM Plus Benefit Packages.

(1) Type A and Type B hospitals:

(a) The Authority shall make a qualified directed payment only if the Type A or Type B hospital meets criteria established by the Authority for the Type A or Type B hospital Quality and Access program in accordance with applicable federal requirements, which may be updated as needed.

(b) The Authority shall make a qualified directed payment for each inpatient and outpatient encounter; one encounter per member, per day, per facility;

(c) QDP amounts shall be at two separate rates; one for inpatient encounters and one for outpatient encounters;

(d) Payment rates shall be set by the Authority and may be adjusted based on actual utilization and available Quality and Access Funds;

(e) The Authority shall create a monthly report to assist CCOs in distributing funds to the appropriate hospital. The report shall be distributed to each CCO and each Type A and Type B hospital;

(f) Within five (5) business days after receipt of the monthly report, the CCO shall submit an electronic payment to an account established by the hospital for the amount indicated on the report;

(g) Adjustments shall be processed weekly through the Medicaid payment system and included in the monthly report.

(2) Public Academic Health Centers:

(a) The Authority shall make a qualified directed payment only if the public academic medical center meets criteria established by the Authority for the Public Academic Medical Center Quality and Access program in accordance with applicable federal requirements, which may be updated as needed.

(b) The Authority shall make a qualified directed payment for each inpatient and outpatient encounter; one encounter per member, per day, per facility;

(c) QDP amounts shall be at two separate rates. One for inpatient encounters and one for outpatient encounters;

(d) Payment rates shall be set by the Authority and may be adjusted based on actual utilization and available Quality and Access Funds;

(e) The Authority shall combine the weekly encounters into a monthly report to assist CCOs in distributing the funds to the appropriate hospital. The report shall be distributed to each CCO and public academic health center;

(f) Within five (5) business days after receipt of the monthly report, the CCO shall submit an electronic payment to an account established by each public health center for the amount indicated on the report;

(g) Adjustments shall be processed weekly through the Medicaid payment system and included in the monthly report.

(3) Diagnosis Related Grouper (DRG) Hospitals:

(a) The Authority shall make a qualified directed payment only if the DRG Hospital meets criteria established by the Authority for the DRG Hospital Quality and Access Pool program in accordance with applicable federal requirements, which may be updated as needed.

(b) The Authority shall make a qualified directed payment for each inpatient and outpatient encounter; one encounter per member, per day, per facility;

(c) QDP amounts shall be at two separate rates. One for inpatient encounters and one for outpatient encounters;

(d) Payment rates shall be set by the Authority and may be adjusted based on actual utilization and available Quality and Access Funds;

(e) The Authority shall create a monthly report to assist CCOs in distributing funds to the appropriate hospital. The report shall be distributed to each CCO and each DRG hospital;

(f) Within five (5) business days after receipt of the monthly report, the CCO shall submit an electronic payment to an account established by the hospital for the amount indicated on the report;

(g) Adjustments shall be processed weekly through the Medicaid payment system and included in the monthly report.

(4) If an error is identified in the monthly report, the CCO shall make the payment based on the original amount provided in the report. The Authority shall identify separately the correction in the following month's report and adjust the total payment amount to account for the error.

Or. Admin. Code § 410-125-0230

DMAP 64-2017, adopt filed 12/29/2017, effective 1/1/2018; DMAP 52-2019, amend filed 12/12/2019, effective 1/1/2020; DMAP 65-2022, amend filed 06/30/2022, effective 7/1/2022; DMAP 55-2023, temporary amend filed 06/30/2023, effective 7/1/2023through 12/27/2023; DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023

Statutory/Other Authority: ORS 413.042 & ORS 414.869

Statutes/Other Implemented: ORS 414.869