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eligibility


 

 


Hospital Eligibility


Eligible hospital types for the program include:

  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 time frame 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.