Or. Admin. R. 410-125-0210 - Third Party Resources and Reimbursement
Current through Register Vol. 60, No. 12, December 1, 2021
(1) The Division of Medical Assistance
Programs (Division) establishes maximum allowable reimbursements for all
services. When clients have other third party payers, the payment made by that
payer is deducted from the Division maximum allowable payment.
(2) The Division will not make any additional
reimbursement when a third party pays an amount equal to or greater than the
Division reimbursement. The Division will not make any additional reimbursement
when a third party pays 100 percent of the billed charges, except when Medicare
Part A is the primary payer.
(3)
When Medicare is Primary:
(a) The Division
calculates the reimbursement for these claims in the same manner as described
in the Inpatient and Outpatient Rates Calculations Sections above;
(b) Payment is the Division allowable
payment, less the Medicare payment, up to the amount of the deductible and/or
coinsurance due. For clients who are Qualified Medicare Beneficiaries the
Division does not make any reimbursement for a service that is not covered by
Medicare. For clients who are Qualified Medicare/Medicaid Beneficiaries the
Division payment is the Division allowable, less the Part A payment up to the
amount of the deductible due for services by either Medicare or
Medicaid.
(4) When
Medicare is Secondary:
(a) An individual
admitted to a hospital may have Medicare Part B, but not Part A. The Division
calculates the reimbursement for these claims in the same manner as described
in the Inpatient Rates Calculations Section above. Payment is the Division
allowable payment, less the Medicare Part B payment;
(b) An individual receiving services in the
outpatient setting may have most services covered by Medicare Part B. The
Division payment is the Division allowable payment, less the Part B payment, up
to the amount of the coinsurance and deductible due. For services provided in
the outpatient setting which are not covered by Medicare, (for example, Take
Home Drugs), the Division payment is the Division allowable payment as
calculated in the Outpatient Rates Calculation Section above;
(c) Most Medicare-Medicaid clients have
Medicare Part A, Part B, and full Medicaid coverage. The Division refers to
these clients as Qualified Medicare-Medicaid Beneficiaries (QMM). However, a
few individuals have Medicare coverage and only limited additional coverage
through Medicaid. The Division refers to these clients as Qualified Medicare
Beneficiaries (QMB). For QMB clients, the Division does not make reimbursement
for a service that is a not covered service for Medicare.
(d) Clients who are Qualified
Medicare-Medicaid Beneficiaries will have coverage for services that are not
covered by Medicare if those services are covered by the Division.
(5) For clients with Physician
Care Organization (PCO) or Prepaid Health Plan (PHP) Coverage, the Division
payment is limited to those services that are not the responsibility of the PCO
or PHP. Payment is made at the Division rates.
(6) Other Insurance:
(a) The Division pays the maximum allowable
payment as described in the Inpatient and Outpatient Rates Calculations, less
any third party payments;
(b) The
Division will not make additional reimbursements when a third party payor
(other than Medicare) pays an amount equal to or greater than the Division
reimbursement, or 100 percent of billed charges.
(7) Medically Needy with Spend-Down.
Reimbursement is the Division maximum allowable payment for covered services
less the amount of the spend-down due.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
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