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Hospital Eligibility

Eligible Hospital Types

  1. Acute Care Hospitals (Including Critical Access Hospitals) 
    • An average length of patient stay of 25 days or fewer
    • A minimum 10% Medicaid patient volume
    • A CMS Certification Number that ends in the range of 0001-0879 or 1300-1399
  2. Children's Hospitals 
    • CCN that ends in the range of 3300-3300

Determining Medicaid Patient Volume

Acute Care and Critical Access Hospitals must have at least 10% Medicaid patient volume. The method to calculate patient volume has changed for program years 2013 and beyond. Medicaid patient volume is calculated using the following formula:

Total Medicaid patient encounters*
_________________________
Total patient encounters*
*In any representative 90-day period within either the prior fiscal year or 12-month timeframe directly preceding the application date.

A Medicaid encounter includes either of the following:

  1. Services rendered to an individual per inpatient discharge where the individual was enrolled in Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) as part of a Medicaid expansion at the time the billable service was provided.

  2. Services rendered in an emergency department on any one day where the individual was enrolled in Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) as part of a Medicaid expansion, at the time the billable service was provided.
PLEASE NOTE: Oregon's CHIP is not part of Medicaid expansion so only Medicaid encounters are applicable to that portion of the calculation. However, the Oregon Health Plan (OHP) includes funding for both Medicaid and CHIP. Because providers cannot differentiate between the two funding streams, providers must reduce all OHP encounters by 4.4%. This is Oregon's statewide rate of CHIP encounters (aka "CHIP proxy"). The CHIP proxy is calculated by taking the total OHP encounters for the selected 90-day period and mulitplying that number by .956 as shown below.

Total Medicaid patient encounters = (Total OHP encounters) X .956

NOTE: An eligible hospital may receive incentive payments from both Medicare and Medicaid if it meets all eligibility criteria. (e.g. Medicaid acute care hospital that is also a Medicare subsection (d) hospital). Hospitals must apply for the incentives with each program in each application year.

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