Or. Admin. Code § 410-146-0020 - Memorandum of Agreement Reimbursement Methodology
(1) In 1996, a Memorandum of Agreement (MOA)
between the Centers for Medicare and Medicaid Services (CMS) and the Indian
Health Service (IHS) established the roles and responsibilities of CMS and IHS
regarding the Division's American Indian/Alaska Native (AI/AN) Program
individuals. The MOA addresses payment for Medicaid services provided to AI/AN
individuals on and after July 11, 1996, through health care facilities owned
and operated by AI/AN tribes and tribal organizations, which are funded through
Title I or V of the Indian Self-Determination and Education Assistance Act (
Public Law 93-638).
(2) The IHS and
CMS, pursuant to an agreement with the Office of Management and Budget (OMB),
developed an all-inclusive rate to be used for billing directly to and
reimbursement by Medicaid. This rate is sometimes referred to as the "OMB,"
"IHS," "All-Inclusive" (AIR), "encounter," or "MOA" rate and is referenced
throughout these rules as the "IHS rate." The IHS rate is updated and published
in the Federal Register each fall:
(a) The
rate is retroactive to the first of the year;
(b) The Division automatically processes a
retroactive billing adjustment each year to ensure payment of the updated rate.
(3) IHS direct health
care service facilities established, operated, and funded by IHS shall enroll
as an IHCP and receive the IHS rate.
(4) Under the MOA, Tribal 638 health care
facilities may choose to be designated a certain type of provider or facility
for enrollment with OHP. The designation determines how the Division pays for
the Medicaid services provided by that provider or facility. Under the MOA, a
Tribal 638 health care facility may do one of the following:
(a) Operate as a Tribal 638 health care
facility. The health center would enroll as an IHCP and choose reimbursement
for services at either:
(A) The IHS rate;
or
(B) A cost-based rate according
to the Prospective Payment System (PPS). Refer to OAR
410-147-0360, Encounter Rate
Determinations, 410-147-0440, Medicare Economic
Index (MEI), 410-147-0480, Cost Statement
(OHP 3027) Instructions, and OAR
410-147-0500, Total Encounters
for Cost Reports; or
(b)
If it so qualifies, operate as any other provider type recognized under the
State Plan and receive that respective reimbursement
methodology.
(5) AI/AN
and the Division's FQHC and RHC program providers may be eligible to receive
the supplemental/wraparound payment for services furnished to clients enrolled
with a Prepaid Health Plan (PHP). Refer to AI/AN OAR 410-146-0420 and FQHC/ RHC
administrative rules OAR chapter 410, division 147.
(6) IHCPs may be eligible for an
administrative match contract with the Division. IHCPs may not participate in
the Medicaid Administrative Claiming (MAC) program if they:
(a) Receive reimbursement for services
according to the cost-based PPS rate methodology; or
(b) Receive financial compensation for
Out-Stationed Outreach Worker (OSOW) activities.
(7) An IHCP that chooses to participate in
the Patient Centered Primary Care Home program (PCPCH) must meet the
requirements and adhere to rules outlined in OAR
409-055-0000 through
409-055-0080 Health Policy and
Analytics and OAR 410-141-0860 Oregon Health Plan
Primary Care Manager and Patient Centered Primary Care Home Provider
Qualification and Enrollment. The PCPCH program is outside the Prospective
Payment System and the IHS/MOA rate. IHCPs who choose to participate and meet
all PCPCH related requirements shall receive a separate reimbursement per the
per member per month (PMPM) payment established by OAR
410-141-0860.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
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