Or. Admin. Code § 410-165-0060
Current through Register Vol. 63, No. 11, November 1, 2024
Section 410-165-0060 - Eligibility(1) There are three categories of eligibility criteria: (a) Eligible professionals; (b) Eligible professionals practicing predominately in a FQHC or RHC; and (2) To be eligible for a Medicaid EHR incentive payment for the program year, an eligible professional as listed in Table 165-0060-1 shall meet the program criteria each year: (a) To be eligible for an incentive payment, an eligible professional shall at a minimum: (A) Meet and follow the scope of practice regulations as applicable for each profession as defined in 42 CFR Part 440 ; (B) Meet the following certified EHR technology and meaningful use requirements for the corresponding year of participation: (i) First year of participation: (I) Adopt, implement, or upgrade certified EHR technology; or (II) Meet the definition of a Meaningful EHR user described in OAR 410-165-0020. (ii) Subsequent years of participation, meet the definition of a Meaningful EHR user described in OAR 410-165-0020. (C) Either not be a hospital-based professional or for program year 2013 or later meet the requirements that allow a reversal of a hospital-based determination. To be considered non-hospital-based in future program years after an initial reversal determination, the professional shall attest in each subsequent program year that the professional continues to meet the requirements. To meet the requirements, the professional shall do all of the following: (i) Fund the acquisition, implementation, and maintenance of certified EHR technology, including supporting hardware and interfaces needed for meaningful use without reimbursement from an eligible hospital and use such certified EHR technology in the inpatient or emergency department of a hospital; (ii) Provide documentation to the Program for review and approval for the program year and in accordance with OAR 410-165-0040; (iii) Meet all applicable requirements to receive an incentive payment; and (iv) If attesting to meaningful use, demonstrate using all encounters at all locations equipped with certified EHR technology, including those in the inpatient and emergency departments of the hospital. (D) Meet one of the following criteria: (i) Have a minimum of 30 percent patient volume attributable to individuals receiving Medicaid; or (ii) Be a pediatrician who has a minimum of 20 percent patient volume attributable to individuals receiving Medicaid. (b) An eligible professional shall calculate patient volume as listed in Table 165-0060-2 by using the patient volume calculation method either of patient encounter or of patient panel. The patient panel volume calculation method may be used only when all of the following apply: (A) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and (B) There is an auditable data source to support the patient panel data. (c) An eligible professional shall calculate patient volume as listed in Table 165-0060-2 by using either the patient volume of the eligible professional or the patient volume of the group. The patient volume of the group may be used only when all of the following apply: (A) The group's patient volume is appropriate as a patient volume methodology calculation for the eligible professional; (B) There is an auditable data source to support the group's patient volume determination; (C) All eligible professionals in the group must use the same patient volume calculation method for the program year; (D) The group uses the entire practice or clinic's patient volume and does not limit patient volume in any way; and (E) If an eligible professional works inside and outside of the group, then the patient volume calculation includes only those encounters associated with the group and not the eligible professional's outside encounters. (d) An eligible professional's patient volume must be calculated using one of the following methods: (A) The patient encounter calculation method based on the patient volume of the eligible professional requires that: (i) For program year 2011 or 2012, the eligible professional shall divide the total Medicaid encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period in the preceding calendar year; or (ii) For program year 2013 and later, the eligible professional shall divide the total Medicaid encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period either in the preceding calendar year or in the twelve-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years. (B) The patient encounter calculation method based on the patient volume of the group requires that: (i) For program year 2011 or 2012, the eligible professional shall divide the group's total Medicaid encounters by the group's total patient encounters in any representative, continuous 90-day period in the preceding calendar year; (ii) For program year 2013 and later, the eligible professional shall divide the group's total Medicaid encounters by the group's total patient encounters in any representative, continuous 90-day period either in the preceding calendar year or in the twelve-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years. (C) The patient panel calculation method based on the patient volume of the eligible professional requires that: (i) For program year 2011 or 2012, the eligible professional shall: (I) Add the total Medicaid patients assigned to the eligible professional's panel in any representative, 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the eligible professional's unduplicated Medicaid encounters rendered in the same 90-day period; and (II) Divide the result calculated above in section (1)(d)(C)(i)(I) by the sum of the total patients assigned to the eligible professional's panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period. (ii) For program year 2013 and later, the eligible professional shall: (I) Add the total Medicaid patients assigned to the eligible professional's panel in any representative, 90-day period in either the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the eligible professional's unduplicated Medicaid encounters rendered in the same 90-day period; and (II) Divide the result calculated above in section (2)(d)(C)(ii)(I) by the sum of the total patients assigned to the eligible professional's panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and (III) Not use the same 90-day timeframe to calculate patient volume in different program years. (D) The patient panel calculation method based on the patient volume of the group requires that: (i) For program year 2011 or 2012, the eligible professional shall: (I) Add the total Medicaid patients assigned to the group's panel in any representative, 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the group's unduplicated Medicaid encounters in the same 90-day period; and (II) Divide the result calculated above in section (1)(d)(D)(i)(I) by the sum of the total patients assigned to the group's panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period. (ii) For program year 2013 and later, the eligible professional shall: (I) Add the total Medicaid patients assigned to the group's panel in any representative, 90-day period in either the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the group's unduplicated Medicaid encounters that same 90-day period; (II) Divide the result calculated above in section (1)(d)(D)(ii)(I) by the sum of the total patients assigned to the group's panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and (III) Not use the same 90-day timeframe to calculate patient volume in different program years. (3) To be eligible for a Medicaid EHR incentive payment for the program year, an eligible professional practicing predominantly in an FQHC or an RHC, as listed in Table 165-0060-1, must meet the Program eligibility criteria each year by meeting either section (2) of this rule or by meeting the following FQHC and RHC specific criteria: (a) At a minimum, the eligible professional shall: (A) Meet and follow the scope of practice regulations as applicable for each professional as prescribed by 42 CFR Part 440 ; (B) Meet the following certified EHR technology and meaningful use requirements for the corresponding year of participation: (i) First year of participation: (I) Adopt, implement, or upgrade certified EHR technology; or (II) Meet the definition of a meaningful EHR user described in OAR 410-165-0020. (ii) Subsequent years of participation, meet the definition of a meaningful EHR user described in OAR 410-165-0020. (C) Have a minimum of 30 percent patient volume attributable to needy individuals. (b) An eligible professional shall calculate patient volume as listed in Table 165-0060-3 by using the patient volume calculation method either of patient encounter or of patient panel. The patient panel volume calculation method may be used only when all of the following apply: (A) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and (B) There is an auditable data source to support the patient panel data. (c) An eligible professional must calculate patient volume as listed in Table 165-0060-3 by using either the patient volume of the eligible professional or the patient volume of the group. The group's patient volume may be used only when all of the following apply: (A) The group's patient volume is appropriate as a patient volume methodology calculation for the eligible professional; (B) There is an auditable data source to support the group's patient volume determination; (C) All eligible professionals in the group shall use the same patient volume calculation method for the program year; (D) The group uses the entire practice or clinic's patient volume and does not limit patient volume in any way; and (E) If an eligible professional works inside and outside of the group, the patient volume calculation includes only those encounters associated with the group and not the outside encounters. (d) An eligible professional's needy individual patient volume shall be calculated using one of the following methods: (A) The patient encounter calculation method based on the eligible professional's patient volume: (i) For program year 2011 or 2012, the eligible professional shall divide the total needy individual encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period in the preceding calendar year; (ii) For program year 2013 and later, the eligible professional shall divide the total needy individual encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period either in the preceding calendar year or in the12-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years. (B) The patient encounter calculation method based on the patient volume of the group requires that: (i) For program year 2011 or 2012, the eligible professional shall divide the group's total needy individual encounters by the group's total patient encounters in any representative, continuous 90-day period in the preceding calendar year; (ii) For program year 2013 and later, divide the group's total needy individual encounters by the group's total patient encounters in any representative, continuous 90-day period either in the preceding calendar year or in the 12-month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.(C) The patient panel calculation method based on the patient volume of the eligible professional requires that: (i) For program year 2011 or 2012, the eligible professional shall: (I) Add the total needy individual patients assigned to the eligible professional's panel in any representative, 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the eligible professional's unduplicated needy individual encounters rendered in the same 90-day period; and (II) Divide the result calculated above in section (2)(d)(C)(i)(I) by the sum of the total patients assigned to the eligible professional's panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period.(ii) For program year 2013 and later, the eligible professional shall: (I) Add the total needy individual patients assigned to the eligible professional's panel in any representative, 90-day period either in the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the eligible professional's unduplicated needy individual encounters rendered the same 90-day period; (II) Divide the result calculated above in section (2)(d)(C)(ii)(I) by the sum of the total patients assigned to the eligible professional's panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and (III) Not use the same 90-day timeframe to calculate patient volume in different program years.(D) The patient panel calculation method based on the patient volume of the group requires that: (i) For program year 2011 or 2012, the eligible professional shall: (I) Add the total needy individual patients assigned to the group's panel in any representative, 90-day period in the prior calendar year, provided at least one needy individual encounter took place with the patient in the preceding calendar year, to the group's unduplicated Medicaid encounters in the same 90-day period; and (II) Divide the result calculated above in section (2)(d)(D)(i)(I) by the sum of the total patients assigned to the group's panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period. (ii) For program year 2013 and later, the eligible professional shall: (I) Add the total needy individual patients assigned to the group's panel in any representative, 90-day period either in the preceding calendar year or during the 12-month timeframe preceding the attestation date, provided at least one needy individual encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the group's unduplicated Medicaid encounters that same 90-day period; (II) Divide the result calculated above in section (2)(d)(D)(ii)(I) by the sum of the total patients assigned to the group's panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and (III) Not use the same 90-day timeframe to calculate patient volume in different program years. (4) To be eligible for a Medicaid EHR incentive payment for the program year, an eligible hospital shall meet the Program criteria each year: (a) To be eligible for an incentive payment, an eligible hospital shall meet the certified EHR technology and meaningful use requirements for the corresponding year of participation: (A) First year of participation: (i) Adopt, implement, or upgrade certified EHR technology; (ii) Eligible hospitals that are children's hospitals shall meet the definition of a meaningful EHR user; or (iii) Eligible hospitals that participate in both the Medicare and Medicaid EHR Incentive Programs shall demonstrate meaningful use under the Medicare EHR Incentive Program to CMS and be deemed a meaningful EHR user for the program year. (B) Subsequent years of participation: (i) Eligible hospitals that participate in both the Medicare and Medicaid EHR Incentive Programs shall demonstrate meaningful use under the Medicare EHR Incentive Program to CMS and be deemed a meaningful EHR user for the program year; or (ii) Eligible hospitals that are children's hospitals shall meet the definition of a meaningful EHR user; (b) If an eligible hospital is an acute care hospital, it shall calculate patient volume by dividing the total eligible hospital Medicaid encounters by the total encounters in any representative, continuous 90-day period: (A) For program year 2011 and 2012, in the preceding federal fiscal year; (B) For program year 2013 and later, either in the preceding federal fiscal year or in the 12-month timeframe preceding the attestation date. The eligible hospital may not use the same 90-day timeframe to calculate patient volume in different program years. (5) Table 165-0060-1. [Table not included. See ED. NOTE.](6) Table 165-0060-2. [Table not included. See ED. NOTE.](7) Table 165-0060-3. [Table not included. See ED. NOTE.]Or. Admin. Code § 410-165-0060
DMAP 20-2011, f. 7-21-11, cert. ef. 7-22-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13; DMAP 20-2015, f. & cert. ef. 4/8/2015; DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16; DMAP 47-2016, f. 7-18-16, cert. ef. 8/1/2016; DMAP 18-2017, f. 5-31-17, cert. ef. 6/2/2017Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.042 & 414.033