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DEPARTMENT OF HUMAN SERVICES,

AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES




 

DIVISION 355
MEDICALLY INVOLVED CHILDREN'S PROGRAM

411-355-0000
Statement of Purpose
(1) The rules in OAR chapter 411, division
355 establish the policy of, and prescribe the standards and procedures for, the
provision of services for children enrolled in the Medically Involved Children's
Program.
(2) MICP services are exclusively
intended to enable a child who meets the nursing facility level of care to return
to the family home, or remain at the family home, with specialized supports and
services. MICP services specifically preserve the capacity of a parent to care for
their child, assure the health and safety of the child within the family home, and
enable a child who has been separated from their family due to their health and
medical care needs to return to the family home to prevent out of home placement.
MICP services complement and supplement the services that are available through
the State Medicaid Plan and other federal, state, and local programs as well as
the natural supports that families and communities provide.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0010
Definitions
Unless the context indicates otherwise,
the following definitions and the definitions in OAR 411-317-0000 apply to the rules
in OAR chapter 411, division 355:
(1) "Abuse" means "abuse"
of a child as defined in ORS 419B.005.
(2) "ADL" means "activities
of daily living". ADL are basic personal everyday activities, such as eating, using
the restroom, grooming, dressing, bathing, and transferring.
(3) "Administrator Review"
means the Director of the Department reviews a decision upon request, including
the documentation related to the decision, and issues a determination.
(4) "Aide" means a non-licensed
caregiver who may, or may not, be a certified nursing assistant.
(5) "Alternative Resources"
mean possible resources for the provision of supports to meet the needs of a child.
Alternative resources include, but are not limited to, private or public insurance,
vocational rehabilitation services, supports available through the Oregon Department
of Education, or other community supports.
(6) "Assistive Devices" mean
the devices, aids, controls, supplies, or appliances described in OAR 411-355-0040
that are necessary to enable a child to increase the ability of the child to perform
ADL and IADLs or to perceive, control, or communicate with the home and community
environment in which the child lives.
(7) "Assistive Technology"
means the devices, aids, controls, supplies, or appliances described in OAR 411-355-0040
that are purchased to provide support for a child and replace the need for direct
interventions to enable self-direction of care and maximize independence of the
child.
(8) "Attendant Care" means
assistance with ADL, IADL, and health-related tasks through cueing, monitoring,
reassurance, redirection, set-up, hands-on, standby assistance, and reminding as
described in OAR 411-355-0040.
(9) "Background Check" means
a criminal records check and abuse check as defined in OAR 407-007-0210.
(10) "Behavior Consultant"
means a contractor with specialized skills as described in OAR 411-355-0050 who
conducts functional assessments and develops a Behavior Support Plan.
(11) "Behavior Support Plan"
means the written strategy based on person-centered planning and a functional assessment
that outlines specific instructions for a primary caregiver or provider to follow
in order to reduce the frequency and intensity of the challenging behaviors of a
child and to modify the behavior of the primary caregiver or provider, adjust environment,
and teach new skills.
(12) "Behavior Support Services"
mean the services consistent with positive behavioral theory and practice that are
provided to assist with behavioral challenges of a child that prevents the child
from accomplishing ADL, IADL, health-related tasks, and provides cognitive supports
to mitigate behavior. Behavior support services are provided in the home or community.
(13) "Billing Form" means
the document generated by the Department that acts as a prior authorization, contract,
and payment mechanism for services.
(14) "Case Management" means
the functions performed by a services coordinator. Case management includes, but
is not limited to, determining service eligibility, developing a plan of authorized
services, and monitoring the effectiveness of services and supports.
(15) "CDDP" means "Community
Developmental Disability Program" as defined in OAR 411-320-0020.
(16) "Child" means an individual
who is less than 18 years of age, and applying for, or accepted for, the Medically
Involved Children's Program under the Medically Involved Model Waiver.
(17) "Chore Services" mean
the services described in OAR 411-355-0040 that are needed to restore a hazardous
or unsanitary situation in the family home to a clean, sanitary, and safe environment.
(18) "Community Nursing Services"
mean the nursing services described in OAR 411-355-0040 that focus on the chronic
and ongoing health and safety needs of a child living in the family home. Community
nursing services include an assessment, monitoring, delegation, training, and coordination
of services. Community nursing services are provided according to the rules in OAR
chapter 411, division 048 and the Oregon State Board of Nursing rules in OAR chapter
851.
(19) "Community Transportation"
means the services described in OAR 411-355-0040 that enable a child to gain access
to community-based state plan and waiver services, activities, and resources that
are not medical in nature. Community transportation is provided in the area surrounding
the family home that is commonly used by people in the same area to obtain ordinary
goods and services.
(20) "Cost Effective" means
being responsible and accountable with Department resources by offering less costly
alternatives when providing choices that adequately meet the support needs of a
child. Less costly alternatives include other programs available from the Department
and the utilization of assistive devices, natural supports, environmental modifications,
and alternative resources. Less costly alternatives may include resources not paid
for by the Department.
(21) "Delegation" is the
process by which a registered nurse authorizes an unlicensed person to perform nursing
tasks and confirms that authorization in writing. Delegation may occur only after
a registered nurse follows all steps of the delegation process as outlined in OAR
chapter 851, division 047.
(22) "Department" means the
Department of Human Services.
(23) "Designated Representative"
means any adult who is not a paid provider of ODDS funded services, such as a family
member or advocate, who is chosen by a parent or guardian and authorized by the
parent or guardian to serve as the representative of the parent or guardian in connection
with the provision of ODDS funded supports. A parent or guardian is not required
to appoint a designated representative.
(24) "Director" means the
Director of the Department of Human Services, Office of Developmental Disability
Services, or the designee of the Director.
(25) "Employer of Record"
means, for the purpose of obtaining MICP services through a personal support worker
as described in these rules, the parent or guardian or a person selected by the
parent or guardian to act on the behalf of the parent or guardian to conduct the
employer responsibilities described in OAR 411-355-0045. An employer of record may
also be a designated representative.
(26) "Employer-Related Supports"
mean the activities that assist a family with directing and supervising provision
of services described in the ISP for a child. Employer-related supports may include,
but are not limited to:
(a) Education about employer
responsibilities;
(b) Orientation to basic
wage and hour issues;
(c) Use of common employer-related
tools such as service agreements; and
(d) Fiscal intermediary services.
(27) "Entry" means admission
to a Department-funded disability service.
(28) "Environmental Modifications"
mean the physical adaptations described in OAR 411-355-0040 that are necessary to
ensure the health, welfare, and safety of a child in the family home, or that are
necessary to enable the child to function with greater independence around the family
home or lead to a substitution for, or decrease in, direct human assistance to the
extent expenditures would otherwise be made for human assistance.
(29) "Environmental Safety
Modifications" mean the physical adaptations described in OAR 411-355-0040 that
are made to the exterior of a family home as identified in the ISP for a child to
ensure the health, welfare, and safety of the child or to enable the child to function
with greater independence around the family home or lead to a substitution for,
or decrease in direct human assistance to the extent expenditures would otherwise
be made for human assistance.
(30) "Exit" means termination
or discontinuance of MICP services.
(31) "Expenditure Guidelines"
mean the guidelines published by the Department that describe allowable uses for
MICP funds. The Department incorporates the Expenditure Guidelines into these rules
by this reference. The Expenditure Guidelines are maintained by the Department at:
http://www.oregon.gov/dhs/dd/. Printed copies may be obtained by calling (503) 945-6398
or writing the Department of Human Services, Developmental Disabilities, ATTN: Rules
Coordinator, 500 Summer Street NE, E-48, Salem, Oregon 97301.
(32) "Family":
(a) Means a unit of two or
more people that includes at least one child where the primary caregiver is:
(A) Related to the child
by blood, marriage, or legal adoption; or
(B) In a domestic relationship
where partners share:
(i) A permanent residence;
(ii) Joint responsibility
for the household in general, such as child-rearing, maintenance of the residence,
and basic living expenses; and
(iii) Joint responsibility
for supporting a child when the child is related to one of the partners by blood,
marriage, or legal adoption.
(b) The term "family" is
defined as described above for purposes of:
(A) Determining the eligibility
of a child for MICP services as a resident in the family home;
(B) Identifying people who
may apply, plan, and arrange for individual services; and
(C) Determining who may receive
family training.
(33) "Family Home" means
the primary residence for a child that is not under contract with the Department
to provide services as a certified foster home or a licensed or certified residential
care facility, assisted living facility, nursing facility, or other residential
setting.
(34) "Family Training" means
the training services described in OAR 411-355-0040 that are provided to a family
to increase the capacity of the family to care for, support, and maintain a child
in the family home.
(35) "Functional Needs Assessment":
(a) Means the comprehensive
assessment or reassessment that:
(A) Documents physical, mental,
and social functioning;
(B) Identifies risk factors
and support needs; and
(C) Determines the service
level.
(b) The functional needs
assessment for a child enrolled in MICP services is known as the Child Needs Assessment
(CNA). Effective December 31, 2014, the Department incorporates Version C of the
CNA into these rules by this reference. The CNA is maintained by the Department
at: http://www.dhs.state.or.us/spd/tools/dd/CNAchildInhome.xls. A printed copy of
a blank CNA may be obtained by calling (503) 945-6398 or writing the Department
of Human Services, Developmental Disabilities, ATTN: Rules Coordinator, 500 Summer
Street NE, E-48, Salem, OR 97301.
(36) "General Business Provider"
means an organization or entity selected by a parent or guardian and paid with MICP
funds that:
(a) Is primarily in business
to provide the service chosen by the parent or guardian to the general public;
(b) Provides services for
the child through employees, contractors, or volunteers; and
(c) Receives compensation
to recruit, supervise, and pay the person who actually provides support for the
child.
(37) "Guardian" means the
parent of a minor child or a person or agency appointed and authorized by a court
to make decisions about services for a child.
(38) "IADL" means "instrumental
activities of daily living". IADL include activities other than ADL required to
enable a child to be independent in the family home and community, such as:
(a) Meal planning and preparation;
(b) Managing personal finances;
(c) Shopping for food, clothing,
and other essential items;
(d) Performing essential
household chores;
(e) Communicating by phone
or other media; and
(f) Traveling around and
participating in the community.
(39) "Independent Provider"
means a person selected by a parent or guardian and paid with MICP funds to directly
provide services to a child.
(40) "Individual-Directed
Goods and Services" mean the services, equipment, or supplies described in OAR 411-355-0040,
not otherwise provided through other waiver or state plan services, that address
an identified need in an ISP. Individual-directed goods and services may include
services, equipment, or supplies that improve and maintain the full membership of
a child in the community.
(41) "ISP" means "Individual
Support Plan". An ISP includes the written details of the supports, activities,
and resources required for a child to achieve and maintain personal goals and health
and safety. The ISP is developed at least annually to reflect decisions and agreements
made during a person-centered process of planning and information gathering. The
ISP reflects services and supports that are important to meet the needs of the child
identified through a functional needs assessment as well as the preferences for
providers, delivery, and frequency of services and supports. The ISP is the plan
of care for Medicaid purposes and reflects whether services are provided through
a waiver, the Community First Choice state plan, natural supports, or alternative
resources.
(42) "Level of Care" means
a child meets the institutional level of care for a nursing facility:
(a) The child has a documented
medical condition and demonstrates the need for active treatment as assessed by
the medically involved criteria; and
(b) The medical condition
requires the care and treatment of services normally provided in a nursing facility.
(43) "Medically Involved
Criteria" means the criteria used by the Department to evaluate the intensity of
the challenges presented by a child eligible for MICP services.
(44) "MICP" means "Medically
Involved Children's Program". MICP is the waiver granted by the federal Centers
for Medicare and Medicaid Services that allows Title XIX funds to be spent on a
child living in the family home who otherwise would have to be served in a nursing
facility if the waiver program was not available.
(45) "Natural Supports" mean
the parental responsibilities for a child who is less than18 years of age and the
voluntary resources available to the child from the relatives, friends, neighbors,
and the community that are not paid for by the Department.
(46) "Nursing Service Plan"
means the plan that is developed by a registered nurse based on an initial nursing
assessment, reassessment, or an update made to a nursing assessment as the result
of a monitoring visit.
(a) The Nursing Service Plan
is specific to a child and identifies the diagnoses and health needs of the child
and any service coordination, teaching, or delegation activities.
(b) The Nursing Service Plan
is separate from the ISP as well as any service plans developed by other health
professionals.
(47) "Nursing Tasks" mean
the care or services that require the education and training of a licensed professional
nurse to perform. Nursing tasks may be delegated.
(48) "ODDS" means the Department
of Human Services, Office of Developmental Disability Services.
(49) "OHP" means the Oregon
Health Plan.
(50) "OHP Plus" means only
the Medicaid benefit packages provided under OAR 410-120-1210(4)(a) and (b). This
excludes individuals receiving Title XXI benefits.
(51) "OIS" means the "Oregon
Intervention System". OIS is the system of providing training of elements of positive
behavior support and non-aversive behavior intervention. OIS uses principles of
pro-active support and describes approved protective physical intervention techniques
that are used to maintain health and safety.
(52) "OSIPM" means "Oregon
Supplemental Income Program-Medical" as described in OAR 461-001-0030. OSIPM is
Oregon Medicaid insurance coverage for children who meet the eligibility criteria
described in OAR chapter 461.
(53) "Parent" means the biological
parent, adoptive parent, or stepparent of a child. Unless otherwise specified, references
to parent also include a person chosen by the parent or guardian to serve as the
designated representative of the parent or guardian in connection with the provision
of ODDS funded supports.
(54) "Person-Centered Planning":
(a) Means a timely and formal
or informal process driven by a child, that includes people chosen by the child
and their parent or guardian, ensures the child directs the process to the maximum
extent possible, and assures the child is enabled to make informed choices and decisions
consistent with 42 CFR 441.540.
(b) Person-centered planning
includes gathering and organizing information to reflect what is important to and
for the child and to help:
(A) Determine and describe
choices about personal goals, activities, services, providers, service settings,
and lifestyle preferences;
(B) Design strategies and
networks of support to achieve goals and a preferred lifestyle using individual
strengths, relationships, and resources; and
(C) Identify, use, and strengthen
naturally occurring opportunities for support at home and in the community.
(c) The methods for gathering
information vary, but all are consistent with the cultural considerations, needs,
and preferences of the child.
(55) "Personal Support Worker"
means "personal support worker" as defined in OAR 411-375-0010.
(56) "Positive Behavioral
Theory and Practice" means a proactive approach to behavior and behavior interventions
that:
(a) Emphasizes the development
of functional alternative behavior and positive behavior intervention;
(b) Uses the least intrusive
intervention possible;
(c) Ensures that abusive
or demeaning interventions are never used; and
(d) Evaluates the effectiveness
of behavior interventions based on objective data.
(57) "Primary Caregiver"
means the parent, guardian, relative, or other non-paid parental figure of a child
that provides direct care at the times that a paid provider is not available. In
this context, the term parent or guardian may include a designated representative.
(58) "Protective Physical
Intervention" means any manual physical holding of, or contact with, a child that
restricts freedom of movement.
(59) "Provider" means a person,
agency, organization, or business selected by a parent or guardian that provides
recognized Department-funded services and is approved by the Department or other
appropriate agency to provide Department-funded services. A provider is not a primary
caregiver.
(60) "Provider Organization"
means an entity licensed or certified by the Department that is selected by a parent
or guardian and paid with MICP funds that:
(a) Is primarily in business
to provide supports for children with disabilities;
(b) Provides supports for
a child through employees, contractors, or volunteers; and
(c) Receives compensation
to recruit, supervise, and pay the person who actually provides support for the
child.
(61) "Relief Care" means
the intermittent services described in OAR 411-355-0040 that are provided on a periodic
basis for the relief of, or due to the temporary absence of, a primary caregiver.
(62) "Scope of Work" means
the written statement of all proposed work requirements for an environmental modification
which may include dimensions, measurements, materials, labor, and outcomes necessary
for a contractor to submit a proposal to complete such work. The scope of work is
specific to the identified tasks and requirements necessary to address the needs
outlined in the supplemental assessment referenced in an ISP and relating to the
ADL, IADL, and health-related tasks of a child as discussed by the parent or guardian,
services coordinator, and ISP team.
(63) "Service Agreement":
(a) Is the written agreement
consistent with an ISP that describes at a minimum:
(A) Type of service to be
provided;
(B) Hours, rates, location
of services, and expected outcomes of services; and
(C) Any specific individual
health, safety, and emergency procedures that may be required, including action
to be taken if a child is unable to provide for their own safety and the child is
missing while in the community under the service of a contractor or provider organization.
(b) For employed personal
support workers, the service agreement serves as the written job description.
(64) "Service Level" means
the amount of attendant care, hourly relief care, or skills training services determined
necessary by a functional needs assessment and medically involved criteria and made
available to meet the identified support needs of a child.
(65) "Services Coordinator"
means an employee of a CDDP, the Department, or other agency that contracts with
the county or Department who provides case management services including, but not
limited to, planning, procuring, coordinating, and monitoring services who ensures
the eligibility of a child for services. The services coordinator acts as the proponent
for children enrolled in the MICP and their families and is the person-centered
plan coordinator for the child as defined in the Community First Choice state plan
amendment.
(66) "Skills Training" means
the activities described in OAR 411-355-0040 that are intended to maximize the independence
of a child through training, coaching, and prompting the child to accomplish ADL,
IADL, and health-related skills.
(67) "Social Benefit" means
the service or financial assistance solely intended to assist a child enrolled in
the MICP to function in society on a level comparable to that of a child not enrolled
in the MICP. Social benefits are pre-authorized by a services coordinator and provided
according to the description and limits written in an ISP.
(a) Social benefits may not:
(A) Duplicate benefits and
services otherwise available to a child regardless of a disability;
(B) Replace normal parental
responsibilities for the services, education, recreation, and general supervision
of a child;
(C) Provide financial assistance
with food, clothing, shelter, and laundry needs common to a child with or without
a disability; or
(D) Replace other governmental
or community services available to a child.
(b) Assistance provided as
a social benefit is reimbursement for an expense previously authorized in an ISP
or prior payment in anticipation of an expense authorized in a previously authorized
ISP.
(c) Assistance provided as
a social benefit may not exceed the actual cost of the support required by a child
to be supported in the family home.
(68) "Special Diet" means
the specially prepared food or particular types of food described in OAR 411-355-0040
that are specific to the medical condition or diagnosis of a child and in support
of an evidence-based treatment regimen.
(69) "Specialized Medical
Supplies" mean the medical and ancillary supplies described in OAR 411-355-0040,
such as:
(a) Necessary medical supplies
specified in an ISP that are not available through state plan or alternative resources;
(b) Ancillary supplies necessary
to the proper functioning of items necessary for life support or to address physical
conditions; and
(c) Supplies necessary for
the continued operation of augmentative communication devices or systems.
(70) "Substantiated" means
an abuse investigation has been completed by the Department or the designee of the
Department and the preponderance of the evidence establishes the abuse occurred.
(71) "Supplant" means take
the place of.
(72) "Support" means the
assistance that a child and a family requires, solely because of the effects of
a disability or medical condition of the child, to maintain or increase the age-appropriate
independence of the child, achieve age-appropriate community presence and participation
of the child, and to maintain the child in the family home. Support is subject to
change with time and circumstances.
(73) "These Rules" mean the
rules in OAR chapter 411, division 355.
(74) "Transition Costs" mean
the expenses described in OAR 411-350-0050 required for a child to make the transition
to the family home from a nursing facility, or intermediate care facility for individuals
with intellectual or developmental disabilities.
(75) "Unacceptable Background
Check" means an administrative process that produces information related to the
background of a person that precludes the person from being an independent provider
for one or more of the following reasons:
(a) Under OAR 407-007-0275,
the person applying to be an independent provider has been found ineligible due
to ORS 443.004;
(b) Under OAR 407-007-0275,
the person was enrolled as an independent provider for the first time, or after
any break in enrollment, after July 28, 2009 and has been found ineligible due to
ORS 443.004; or
(c) A background check and
fitness determination has been conducted resulting in a "denied" status as defined
in OAR 407-007-0210.
(76) "Vehicle Modifications"
mean the adaptations or alterations described in OAR 411-350-0050 that are made
to the vehicle that is the primary means of transportation for a child in order
to accommodate the service needs of the child.
(77) "Waiver Services" mean
the menu of disability related services and supplies that are specifically identified
by the Medically Involved Model Waiver.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 5-2010, f. 6-29-10,
cert. ef. 7-1-10; SPD 29-2013(Temp), f. & cert. ef. 7-2-13 thru 12-29-13; SPD
56-2013, f. 12-27-13, cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert. ef.
8-1-15 thru 1-27-16
411-355-0020
Eligibility
(1) ELIGIBILITY. In order to be eligible
for the MICP, a child must:
(a) Be under the age of 18;
(b) Be an Oregon resident
who meets the citizenship and alien status requirements of OAR 461-120-0110;
(c) Be receiving Medicaid
Title XIX benefits under OSIPM;
(d) For a child with excess
income, contribute to the cost of services pursuant to OAR 461-160-0610 and OAR
461-160-0620;
(e) Meet the level of care
as defined in OAR 411-355-0010;
(f) Be accepted by the Department
by scoring 100 or greater on the medically involved criteria and maintain an eligibility
score of 100 or greater as determined by a reassessment annually;
(g) Require services offered
under the MICP;
(h) Reside in the family
home; and
(i) Be safely served in the
family home. This includes, but is not limited to, a qualified primary caregiver
demonstrating the willingness, skills, and ability to provide direct care as outlined
in an ISP in a cost effective manner, as determined by a services coordinator within
the limitations of OAR 411-355-0040, and participate in planning, monitoring, and
evaluation of the MICP services provided.
(2) TRANSFER OF ASSETS.
(a) As of October 1, 2014,
a child receiving medical benefits under OAR chapter 410, division 200 requesting
Medicaid coverage for services in a nonstandard living arrangement (see OAR 461-001-0000)
is subject to the requirements of the rules regarding transfer of assets (see OAR
461-140-0210 to 461-140-0300) in the same manner as if the child was requesting
these services under OSIPM. This includes, but is not limited to, the following
assets:
(A) An annuity evaluated
according to OAR 461-145-0022;
(B) A transfer of property
when a child retains a life estate evaluated according to OAR 461-145-0310;
(C) A loan evaluated according
to OAR 461-145-0330; or
(D) An irrevocable trust
evaluated according to OAR 461-145-0540.
(b) When a child is considered
ineligible for MICP services due to a disqualifying transfer of assets, the parent
or guardian and child must receive a notice meeting the requirements of OAR 461-175-0310
in the same manner as if the child was requesting services under OSIPM.
(3) ENROLLMENT. If a child
meets the criteria of section (1) of this rule and space is available in the MICP,
the priority of the child for enrollment is in accordance with ORS 417.345, Medically
Involved Model Waiver requirements. The date the initial application is complete
is the date that the Department receives all of the required demographic and referral
information on the child.
(4) INELIGIBILITY. A child
is not eligible for the MICP if the child:
(a) Continues to reside in
a medical hospital, psychiatric hospital, school, sub-acute facility, nursing facility,
intermediate care facility for individuals with intellectual or developmental disabilities,
foster home, or other 24-hour residential setting;
(b) Does not require waiver
services or Community First Choice state plan services;
(c) Receives sufficient family,
government, or community resources available to provide for his or her care; or
(d) Cannot be safely served
in the family home as described in section (1)(i) of this rule.
(5) REDETERMINATION. The
Department redetermines the eligibility of a child for the MICP using the medically
involved criteria at least every 12 months, or as the status of the child changes.
(6) TRANSITION. A child whose
reassessment score on the medically involved criteria is less than 100 is transitioned
out of the MICP within 30 days. The child must exit from the MICP at the end of
the 30 day transition period.
(7) DISENROLLMENT.
(a) A child is disenrolled
from the MICP:
(A) At the oral or written
request of a parent or guardian to end the service relationship; or
(B) In any of the following
circumstances:
(i) The child no longer meets
the eligibility criteria in section (1) of this rule;
(ii) The child does not require
waiver services or Community First Choice state plan services;
(iii) There are sufficient
family, government, community, or alternative resources available to provide for
the care of the child;
(iv) The child may not be
safely served in the family home as described in section (1)(i) of this rule;
(v) The parent or guardian
either cannot be located or has not responded after 30 days of repeated attempts
by a services coordinator to complete ISP development and monitoring activities
and does not respond to a notice of intent to terminate;
(vi) The services coordinator
has sufficient evidence that the parent or guardian has engaged in fraud or misrepresentation,
failed to use resources as agreed upon in the ISP, refused to cooperate with documenting
expenses of MICP funds, or otherwise knowingly misused public funds associated with
the MICP;
(vii) The child is incarcerated
or admitted to a medical hospital, psychiatric hospital, sub-acute facility, nursing
facility, intermediate care facility for individuals with intellectual or developmental
disabilities, foster home, or other 24-hour residential setting and it is determined
that the child is not returning to the family home or is not returning to the family
home after 90 consecutive days; or
(viii) The child does not
reside in Oregon.
(b) In the event a child
is disenrolled from the MICP, a written Notification of Planned Action must be provided
as described in OAR chapter 411, division 318.
(8) WAIT LIST. If the maximum
number of children allowed on the Medically Involved Model Waiver are enrolled and
being served, the Department may place a child eligible for the MICP on a wait list.
A child on the wait list may access other Medicaid-funded services or General Fund
services for which the child is determined eligible.
(a) The date of the initial
completed application for the MICP determines the order on the wait list. A child,
who previously received children's intensive in-home services that currently meets
the criteria for eligibility as described in section (1) of this rule, is put on
the wait list as of the date the original application for MICP services was complete.
(b) The date the application
for the MICP is complete is the date that the Department has the required demographic
data and referral information for the child.
(c) Children on the wait
list are prioritized for entry if they are currently residing in a nursing facility
for long term care and whose family wishes them to return home, enrolled in another
waiver meeting the medically involved criteria, are residing in the community and
at imminent risk of placement in a nursing facility, and as space on the Medically
Involved Model Waiver allows. An evaluation is completed prior to entry to determine
current eligibility.
(9) ASSESSMENT. Anyone may
request an assessment for a child for MICP services.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 29-2013(Temp), f. & cert. ef. 7-2-13 thru 12-29-13; SPD 56-2013, f. 12-27-13,
cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert. ef. 8-1-15 thru 1-27-16
411-355-0030
Service Planning
(1) To develop an ISP, a services coordinator
must complete a functional needs assessment using a person-centered planning approach
and assess the service needs of the child. The assessment must take place in person
and the services coordinator must interview the child’s parent, provider,
and when appropriate, any other person at the parent’s request. The assessment
must identify the following:
(a) The current care needs
of the child including ADL care, medication management, communication, supervisory
needs, and physical environment;
(b) The services for which
the child is currently eligible;
(c) The services currently
being provided;
(d) All available family,
private health insurance, and government or community resources that meet any, some,
or all of the child’s needs; and
(e) Areas of unmet needs.
(2) The service coordinator
must prepare, with the input of the child’s parent and any other person at
the parent’s request, a written ISP that identifies:
(a) The service needs of
the child;
(b) The most cost effective
services for safely and appropriately meeting the child’s service needs; and
(c) The methods, resources,
and strategies that address the child’s service needs.
(3) The ISP must include:
(a) A description of the
supports required, including the reason the support is necessary. The description
must be consistent with the needs identified in the functional needs assessment;
(b) A list of personal, community,
and public resources that are available to the child and how the resources may be
applied to provide the required supports. Sources of support may include waiver
services, state plan services, state general funds, or natural supports;
(c) The maximum hours of
provider services authorized for the child;
(d) The annual average service
level;
(e) The number of hours of
attendant care or other related services authorized for the child;
(f) Additional services authorized
by the Department for the child;
(g) All behavior and specialized
consultant services purchased through the MICP;
(h) The projected date of
when specific services are to begin and end, as well as the end date, if any, of
the period of service covered by the ISP;
(i) Projected costs with
sufficient detail to support estimates;
(j) The manner in which services
are delivered and the frequency of services;
(k) Service providers;
(l) The child’s strengths
and preferences;
(m) If the child has a determined
service level, the clinical and support needs as identified through the functional
needs assessment;
(n) Individually identified
goals and desired outcomes;
(o) The services and supports
(paid and unpaid) to assist the child to achieve identified goals and the providers
of the services and supports, including voluntarily provided natural supports;
(p) The risk factors and
the measures in place to minimize the risk factors, including back-up plans;
(q) The identity of the person
responsible for case management and monitoring the ISP;
(r) The date of the next
ISP review that, at a minimum, must be completed within 12 months of the last ISP;
(s) The Nursing Care Plan
as a supporting document, when one exists;
(t) A provision to prevent
unnecessary or inappropriate care; and
(u) If the child has a determined
service level, any changes in support needs identified through a functional needs
assessment.
(4) The child’s parent
must review the ISP prior to implementation. The parent and the services coordinator
must sign the ISP and a copy must be provided to the parent.
(5) A services coordinator
must reflect significant changes in the needs of a child in the child’s ISP,
as they occur, and provide a copy of the revised ISP to the parent.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 29-2013(Temp), f. & cert. ef. 7-2-13 thru 12-29-13; SPD 56-2013, f. 12-27-13,
cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert. ef. 8-1-15 thru 1-27-16
411-355-0040
Scope of MICP Services and Limitations
(1) MICP services are intended to support,
not supplant, the naturally occurring services provided by a legally responsible
primary caregiver and enable the primary caregiver to meet the needs of caring for
a child on the MICP. MICP services are not meant to replace other available governmental
or community services and supports. All services funded by the Department must be
provided in accordance with the Expenditure Guidelines and based on the actual and
customary costs related to best practice standards of care for children with similar
disabilities.
(2) When multiple children
in the same family home or setting qualify for MICP services, the same provider
may provide services to all qualified children if services may be safely delivered
by a single provider, as determined by the services coordinator.
(3) The use of MICP funds
to purchase supports is limited to:
(a) The service level for
a child as determined by a functional needs assessment. The functional needs assessment
determines the total number of hours needed to meet the identified needs of the
child. The total number of assessed hours may not be exceeded without prior approval
from the Department. The types of services that contribute to the total number of
hours used include attendant care, skills training, hourly relief care, and state
plan personal care service hours as described in OAR chapter 411, division 034;
and
(b) Other services and supports
determined by a services coordinator to be necessary to meet the support needs identified
through a person-centered planning process and consistent with the Expenditure Guidelines.
(4) To be authorized and
eligible for payment by the Department, all MICP services and supports must be:
(a) Directly related to the
disability of a child;
(b) Required to maintain
the health and safety of a child;
(c) Cost effective;
(d) Considered not typical
for a parent or guardian to provide to a child of the same age;
(e) Required to help the
parent or guardian to continue to meet the needs of caring for the child;
(f) Included in an approved
ISP;
(g) Provided in accordance
with the Expenditure Guidelines; and
(h) Based on the actual and
customary costs related to best practice standards of care for children with similar
disabilities.
(5) When conditions of purchases
are met and provided purchases are not prohibited, MICP funds may be used to purchase
a combination of the following supports based upon the needs of a child as determined
by a services coordinator and consistent with a functional needs assessment, initial
or annual ISP, and the OSIPM or OHP Plus benefits the child qualifies for:
(a) Community First Choice
state plan services:
(A) Behavior support services
as described in section (6) of this rule;
(B) Community nursing services
as described in section (7) of this rule;
(C) Environmental modifications
as described in section (8) of this rule;
(D) Attendant care as described
in section (9) of this rule;
(E) Skills training as described
in section (10) of this rule;
(F) Relief care as described
in section (11) of this rule;
(G) Assistive devices as
described in section (12) of this rule;
(H) Assistive technology
as described in section (13) of this rule;
(I) Chore services as described
in section (14) of this rule;
(J) Community transportation
as described in section (15) of this rule; and
(K) Transition costs as described
in section (16) of this rule.
(b) Home and community-based
waiver services:
(A) Case management as defined
in OAR 411-355-0010;
(B) Family training as described
in section (17) of this rule;
(C) Environmental safety
modifications as described in section (18) of this rule;
(D) Vehicle modifications
as described in section (19) of this rule;
(E) Specialized medical supplies
as described in section (20) of this rule;
(F) Special diet as described
in section (21) of this rule; and
(G) Individual-directed goods
and services as described in section (22) of this rule.
(c) State Plan personal care
services.
(6) BEHAVIOR SUPPORT SERVICES.
Behavior support services may be authorized to support a primary caregiver in their
caregiving role and to respond to specific problems identified by a child, primary
caregiver, or a services coordinator. Positive behavior support services are used
to enable a child to develop, maintain, or enhance skills to accomplish ADLs, IADLs,
and health-related tasks.
(a) A behavior consultant
must:
(A) Work with the child and
primary caregiver to identify:
(i) Areas of the family home
life that are of most concern for the child and the parent or guardian;
(ii) The formal or informal
responses the family or the provider has used in those areas; and
(iii) The unique characteristics
of the child and family that may influence the responses that may work with the
child.
(B) Assess the child. The
assessment must include:
(i) Specific identification
of the behaviors or areas of concern;
(ii) Identification of the
settings or events likely to be associated with, or to trigger, the behavior;
(iii) Identification of early
warning signs of the behavior;
(iv) Identification of the
probable reasons that are causing the behavior and the needs of the child that are
met by the behavior, including the possibility that the behavior is:
(I) An effort to communicate;
(II) The result of a medical
condition;
(III) The result of an environmental
cause; or
(IV) The symptom of an emotional
or psychiatric disorder.
(v) Evaluation and identification
of the impact of disabilities (i.e. autism, blindness, deafness, etc.) that impact
the development of strategies and affect the child and the area of concern; and
(vi) An assessment of current
communication strategies.
(C) Develop a variety of
positive strategies that assist the primary caregiver and the provider to help the
child use acceptable, alternative actions to meet the needs of the child in the
safest, most positive, and cost effective manner. These strategies may include changes
in the physical and social environment, developing effective communication, and
appropriate responses by the primary caregiver.
(i) When interventions in
behavior are necessary, the interventions must be performed in accordance with positive
behavioral theory and practice as defined in OAR 411-355-0010.
(ii) The least intrusive
intervention possible to keep the child and others safe must be used.
(iii) Abusive or demeaning
interventions must never be used.
(iv) The strategies must
be adapted to the specific disabilities of the child and the style or culture of
the family.
(D) Develop a written Behavior
Support Plan using clear, concrete language that is understandable to the primary
caregiver and the provider that describes the assessment, strategies, and procedures
to be used;
(E) Develop emergency and
crisis procedures to be used to keep the child, primary caregiver, and the provider
safe. When interventions in the behavior of the child are necessary, positive, preventative,
non-aversive interventions that conform to OIS must be utilized. The use of protective
physical intervention must be part of the Behavior Support Plan for the child. When
protective physical intervention is required, the protective physical intervention
must only be used as a last resort and the provider must be appropriately trained
in OIS;
(F) Teach the primary caregiver
and the provider the strategies and procedures to be used; and
(G) Monitor and revise the
Behavior Support Plan as needed.
(b) Behavior support services
may include:
(A) Training the primary
caregiver or provider of a child;
(B) Developing a visual communication
system as a strategy for behavior support; and
(C) Communicating, as authorized
by a parent or guardian through a release of information, with other professionals
about the strategies and outcomes of the Behavior Support Plan as written in the
Behavior Support Plan within authorized consultation hours only.
(c) Behavior support services
exclude:
(A) Mental health therapy
or counseling;
(B) Health or mental health
plan coverage;
(C) Educational services
including, but not limited to, consultation and training for classroom staff;
(D) Adaptations to meet the
needs of a child at school;
(E) An assessment in a school
setting;
(F) Attendant care;
(G) Relief care; or
(H) Communication or activities
not directly related to the development, implementation, or revision of the Behavior
Support Plan.
(7) COMMUNITY NURSING SERVICES.
(a) Community nursing services
include:
(A) Nursing assessments,
including medication reviews;
(B) Care coordination;
(C) Monitoring;
(D) Development of a Nursing
Service Plan;
(E) Delegation and training
of nursing tasks to a provider and primary caregiver;
(F) Teaching and education
of a primary caregiver and provider and identifying supports that minimize health
risks while promoting the autonomy of a child and self-management of healthcare;
and
(G) Collateral contact with
a services coordinator regarding the community health status of a child to assist
in monitoring safety and well-being and to address needed changes to the ISP for
the child.
(b) Community nursing services
exclude private duty nursing care.
(c) A Nursing Service Plan
must be present when MICP funds are used for community nursing services. A services
coordinator must authorize the provision of community nursing services as identified
in an ISP.
(d) After an initial nursing
assessment, a nursing reassessment must be completed every six months or sooner
if a change in a medical condition requires an update to the Nursing Service Plan.
(8) ENVIRONMENTAL MODIFICATIONS.
(a) Environmental modifications
include, but are not limited to:
(A) An environmental modification
consultation to determine the appropriate type of adaptation;
(B) Installation of shatter-proof
windows;
(C) Hardening of walls or
doors;
(D) Specialized, hardened,
waterproof, or padded flooring;
(E) An alarm system for doors
or windows;
(F) Protective covering for
smoke alarms, light fixtures, and appliances;
(G) Installation of ramps,
grab-bars, and electric door openers;
(H) Adaptation of kitchen
cabinets and sinks;
(I) Widening of doorways;
(J) Handrails;
(K) Modification of bathroom
facilities;
(L) Individual room air conditioners
for a child whose temperature sensitivity issues create behaviors or medical conditions
that put the child or others at risk;
(M) Installation of non-skid
surfaces;
(N) Overhead track systems
to assist with lifting or transferring;
(O) Specialized electric
and plumbing systems that are necessary to accommodate the medical equipment and
supplies necessary for the welfare of the child; and
(P) Adaptations to control
lights, heat, stove, etc.
(b) Environmental modifications
exclude:
(A) Adaptations or improvements
to the family home that are of general utility, such as carpeting, roof repair,
and central air conditioning, unless directly related to the health and safety needs
of the child and identified in the ISP for the child;
(B) Adaptations that add
to the total square footage of the family home except for ramps that attach to the
home for the purpose of entry or exit;
(C) Adaptations outside of
the family home; and
(D) General repair or maintenance
and upkeep required for the family home.
(c) Environmental modifications
must be tied to supporting assessed ADL, IADL, and health-related tasks as identified
in the ISP for the child.
(d) Environmental modifications
are limited to $5,000 per modification. A services coordinator must request approval
for additional expenditures through the Department prior to expenditure. Approval
is based on the service and support needs and goals of the child and the determination
by the Department of appropriateness and cost effectiveness. In addition, separate
environmental modification projects that cumulatively total up to over $5,000 in
a plan year must be submitted to the Department for review,
(e) Environmental modifications
must be completed by a state licensed contractor with a minimum of $1,000,000 liability
insurance. Any modification requiring a permit must be inspected by a local inspector
and certified as in compliance with local codes. Certification of compliance must
be filed in the file for the contractor prior to payment.
(f) Environmental modifications
must be made within the existing square footage of the family home, except for external
ramps, and may not add to the square footage of the family home.
(g) Payment to the contractor
is to be withheld until the work meets specifications.
(h) A scope of work as defined
in OAR 411-355-0010 must be completed for each identified environmental modification
project. All contractors submitting bids must be given the same scope of work.
(i) A services coordinator
must follow the processes outlined in the Expenditure Guidelines for contractor
bids and the awarding of work.
(j) All dwellings must be
in good repair and have the appearance of sound structure.
(k) The identified home may
not be in foreclosure or the subject of legal proceedings regarding ownership.
(l) Environmental modifications
must only be completed to the family home.
(m) Upgrades in materials
that are not directly related to the health and safety needs of the child are not
paid for or permitted.
(n) Environmental modifications
are subject to Department requirements regarding material and construction practices
based on industry standards for safety, liability, and durability, as referenced
in building codes, materials manuals, and industry and risk management publications.
(o) RENTAL PROPERTY.
(A) Environmental modifications
to rental property may not substitute or duplicate services otherwise the responsibility
of the landlord under the landlord tenant laws, the Americans with Disabilities
Act, or the Fair Housing Act.
(B) Environmental modifications
made to a rental structure must have written authorization from the owner of the
rental property prior to the start of the work.
(C) The Department does not
fund work to restore the rental structure to the former condition of the rental
structure.
(9) ATTENDANT CARE. Attendant
care services include direct support provided to a child in the family home or community
by a qualified personal support worker or provider organization. ADL and IADL services
provided through attendant care must support the child to live as independently
as appropriate for the age of the child, support the family in their primary caregiver
role, and be based on the identified goals, preferences, and needs of the child.
The primary caregiver is expected to be present or available during the provision
of attendant care.
(a) ADL services include,
but are not limited to:
(A) Basic personal hygiene
— providing or assisting with needs, such as bathing (tub, bed, bath, shower),
hair care, grooming, shaving, nail care, foot care, dressing, skin care, or oral
hygiene;
(B) Toileting, bowel, and
bladder care — assisting to and from the bathroom, on and off toilet, commode,
bedpan, urinal, or other assistive device used for toileting, changing incontinence
supplies, following a toileting schedule, managing menses, cleansing a child or
adjusting clothing related to toileting, emptying a catheter, drainage bag, or assistive
device, ostomy care, or bowel care;
(C) Mobility, transfers,
and repositioning — assisting with ambulation or transfers with or without
assistive devices, turning a child or adjusting padding for physical comfort or
pressure relief, or encouraging or assisting with range-of-motion exercises;
(D) Nutrition - assisting
with adequate fluid intake or adequate nutrition, assisting with food intake (feeding),
monitoring to prevent choking or aspiration, assisting with adaptive utensils, cutting
food, and placing food, dishes, and utensils within reach for eating;
(E) Delegated nursing tasks;
(F) First aid and handling
emergencies — addressing medical incidents related to the conditions of a
child, such as seizure, aspiration, constipation, or dehydration, responding to
the call of the child for help during an emergent situation, or for unscheduled
needs requiring immediate response;
(G) Assistance with necessary
medical appointments — help scheduling appointments, arranging medical transportation
services, accompaniment to appointments, follow up from appointments, or assistance
with mobility, transfers, or cognition in getting to and from appointments; and
(H) Observation of the status
of a child and reporting of significant changes to a physician, health care provider,
or other appropriate person.
(b) IADL services include,
but are not limited to, the following services provided solely for the benefit of
the child:
(A) Light housekeeping tasks
necessary to maintain the child in a healthy and safe environment - cleaning surfaces
and floors, making the child's bed, cleaning dishes, taking out the garbage, dusting,
and laundry;
(B) Grocery and other shopping
necessary for the completion of other ADL and IADL tasks;
(C) Meal preparation and
special diets;
(D) Cognitive assistance
or emotional support provided to a child - helping the child cope with change and
assisting the child with decision-making, reassurance, orientation, memory, or other
cognitive functions;
(E) Medication and medical
equipment — assisting with ordering, organizing, and administering medications
(including pills, drops, ointments, creams, injections, inhalers, and suppositories),
monitoring a child for choking while taking medications, assisting with the administration
of medications, maintaining equipment, or monitoring for adequate medication supply;
and
(F) Support in the community
around socialization and participation in the community:
(i) Support with socialization
— assisting a child in acquiring, retaining, and improving self-awareness
and self-control, social responsiveness, social amenities, and interpersonal skills;
(ii) Support with community
participation — assisting a child in acquiring, retaining, and improving skills
to use available community resources, facilities, or businesses; and
(iii) Support with communication
— assisting a child in acquiring, retaining, and improving expressive and
receptive skills in verbal and non-verbal language and the functional application
of acquired reading and writing skills.
(c) Assistance with ADLs,
IADLs, and health-related tasks may include cueing, monitoring, reassurance, redirection,
set-up, hands-on, or standby assistance. Assistance may be provided through human
assistance or the use of electronic devices or other assistive devices. Assistance
may also require verbal reminding to complete any of the IADL tasks described in
subsection (b) of this section.
(A) "Cueing" means giving
verbal, audio, or visual cues during an activity to help a child complete the activity
without hands-on assistance.
(B) "Hands-on" means a provider
physically performs all or parts of an activity because a child is unable to do
so.
(C) "Monitoring" means a
provider observes a child to determine if assistance is needed.
(D) "Reassurance" means to
offer a child encouragement and support.
(E) "Redirection" means to
divert a child to another more appropriate activity.
(F) "Set-up" means the preparation,
cleaning, and maintenance of personal effects, supplies, assistive devices, or equipment
so that a child may perform an activity.
(G) "Stand-by" means a provider
is at the side of a child ready to step in and take over the task if the child is
unable to complete the task independently.
(d) Attendant care services
must:
(A) Be prior authorized by
the services coordinator before services begin;
(B) Be delivered through
the most cost effective method as determined by the services coordinator; and
(C) Only be provided when
the child is present to receive services.
(e) Attendant care services
exclude:
(A) Hours that supplant parental
responsibilities or other natural supports and services as defined in this rule
available from the family, community, other government or public services, insurance
plans, schools, philanthropic organizations, friends, or relatives;
(B) Hours solely to allow
the primary caregiver to work or attend school;
(C) Hours that exceed what
is necessary to support the child based on the functional needs assessment and medically
involved criteria;
(D) Support generally provided
for a child of similar age without disabilities by the parent or guardian or other
family members;
(E) Supports and services
in the family home that are funded by Child Welfare;
(F) Educational and supportive
services provided by schools as part of a free and appropriate public education
for children and young adults under the Individuals with Disabilities Education
Act;
(G) Services provided by
the family; and
(H) Home schooling.
(f) Attendant care services
may not be provided on a 24-hour shift-staffing basis.
(10) SKILLS TRAINING. Skills
training is specifically tied to accomplishing ADL, IADL, and other health-related
tasks as identified by the functional needs assessment and ISP and is a means for
a child to acquire, maintain, or enhance independence.
(a) Skills training may be
applied to the use and care of assistive devices and technologies.
(b) Skills training is authorized
when:
(A) The anticipated outcome
of the skills training, as documented in the ISP, is measurable;
(B) Timelines for measuring
progress towards the anticipated outcome are established in the ISP; and
(C) Progress towards the
anticipated outcome are measured and the measurements are evaluated by a services
coordinator no less frequently than every six months, based on the start date of
the initiation of the skills training.
(c) When anticipated outcomes
are not achieved within the timeframe outline in the ISP, the services coordinator
must reassess or redefine the use of skills training with the child for that particular
goal.
(d) Skills training does
not replace the responsibilities of the school system.
(11) RELIEF CARE.
(a) Relief care may not be
characterized as daily or periodic services provided solely to allow the primary
caregiver to attend school or work. Daily relief care may be provided in segments
that are sequential but may not exceed seven consecutive days without permission
from the Department. No more than 14 days of relief care in a plan year are allowed
without approval from the Department.
(b) Relief care may include
both day and overnight services that may be provided in:
(A) The family home;
(B) A licensed or certified
setting;
(C) The home of a qualified
provider chosen by the parent or guardian as a safe setting for the child; or
(D) The community during
the provision of ADL, IADL, health-related tasks, and other supports identified
in the ISP for the child.
(c) Relief care services
are not authorized for the following:
(A) Solely to allow the primary
caregiver of the child to attend school or work;
(B) For more than seven consecutive
overnight stays without permission from the Department;
(C) For more than 10 days
per individual plan year when provided at a camp that meets provider qualifications;
(D) For vacation, travel,
and lodging expenses; or
(E) To pay for room and board.
(12) ASSISTIVE DEVICES. Assistive
devices are primarily and customarily used to meet an ADL, IADL, or health-related
support need. The purchase, rental, or repair of an assistive device must be limited
to the types of equipment that are not excluded under OAR 410-122-0080.
(a) Assistive devices may
be purchased with MICP funds when the disability of a child otherwise prevents or
limits the independence of the child to assist in areas identified in a functional
needs assessment.
(b) Assistive devices that
may be purchased for the purpose described in subsection (a) of this section must
be of direct benefit to the child and may include:
(A) Devices to secure assistance
in an emergency in the community and other reminders, such as medication minders,
alert systems for ADL or IADL supports, or mobile electronic devices.
(B) Assistive devices not
provided by any other funding source to assist and enhance the independence of a
child in performing ADLs or IADLs, such as durable medical equipment, mechanical
apparatus, or electronic devices.
(c) Expenditures for assistive
devices are limited to $5,000 per plan year without Department approval. Any single
purchase costing more than $500 must be approved by the Department prior to expenditure.
Approval is based on the service and support needs and goals of the child and a
determination by the Department of appropriateness and cost-effectiveness.
(d) Devices must be limited
to the least costly option necessary to meet the assessed need of a child.
(e) To be authorized by a
services coordinator, assistive devices must be:
(A) In addition to any assistive
devices, medical equipment, or supplies furnished under OHP, private insurance,
or alternative resources;
(B) Determined necessary
to the daily functions of a child; and
(C) Directly related to the
disability of a child.
(f) Assistive devices exclude:
(A) Items that are not necessary
or of direct medical or remedial benefit to the child or do not address the underlying
need for the device;
(B) Items intended to supplant
similar items furnished under OHP, private insurance, or alternative resources;
(C) Items that are considered
unsafe for a child;
(D) Toys or outdoor play
equipment; and
(E) Equipment and furnishings
of general household use.
(13) ASSISTIVE TECHNOLOGY.
Assistive technology is primarily and customarily used to provide additional safety
and support and replace the need for direct interventions, to enable self-direction
of care, and maximize independence. Assistive technology includes, but is not limited
to, motion or sound sensors, two-way communication systems, automatic faucets and
soap dispensers, incontinence and fall sensors, or other electronic backup systems.
(a) Expenditures for assistive
technology are limited to $5,000 per plan year without Department approval. Any
single purchase costing more than $500 must be approved by the Department prior
to expenditure. A services coordinator must request approval for additional expenditures
through the Department prior to expenditure. Approval is based on the service and
support needs and goals of the child and a determination by the Department of appropriateness
and cost-effectiveness.
(b) Payment for ongoing electronic
back-up systems or assistive technology costs must be paid to providers each month
after services are received.
(A) Ongoing costs do not
include electricity or batteries.
(B) Ongoing costs may include
minimally necessary data plans and the services of a company to monitor emergency
response systems.
(14) CHORE SERVICES. Chore
services may be provided only in situations where no one else is responsible or
able to perform or pay for the services.
(a) Chore services include
heavy household chores, such as:
(A) Washing floors, windows,
and walls;
(B) Tacking down loose rugs
and tiles; and
(C) Moving heavy items of
furniture for safe access and egress.
(b) Chore services may include
yard hazard abatement to ensure the outside of the family home is safe for the child
to traverse and enter and exit the home.
(15) COMMUNITY TRANSPORTATION.
(a) Community transportation
includes, but is not limited to:
(A) Community transportation
provided by a common carrier or bus in accordance with standards established for
these entities;
(B) Reimbursement on a per-mile
basis for transporting a child; or
(C) Assistance with the purchase
of a bus pass.
(b) Community transportation
may only be authorized when natural supports or volunteer services are not available
and one of the following is identified in the ISP for the child:
(A) The child has an assessed
need for ADL, IADL, or a health-related task during transportation; or
(B) The child has either
an assessed need for ADL, IADL, or a health-related task at the destination or a
need for waiver funded services at the destination.
(c) Community transportation
must be provided in the most cost-effective manner which meets the needs identified
in the ISP for the child.
(d) Community transportation
expenses exceeding $500 per month must be approved by the Department.
(e) Community transportation
must be prior authorized by a services coordinator and documented in an ISP. The
Department does not pay any provider under any circumstances for more than the total
number of hours, miles, or rides prior authorized by the services coordinator and
documented in the ISP. Personal support workers who use their own personal vehicles
for community transportation are reimbursed as described in OAR chapter 411, division
375.
(f) Community transportation
excludes:
(A) Medical transportation;
(B) Purchase or lease of
a vehicle;
(C) Routine vehicle maintenance
and repair, insurance, and fuel;
(D) Ambulance services;
(E) Costs for transporting
a person other than the child;
(F) Transportation for a
provider to travel to and from the workplace of the provider;
(G) Transportation that is
not for the sole benefit of the child;
(H) Transportation to vacation
destinations or trips for relaxation purposes;
(I) Transportation provided
by family members;
(J) Transportation normally
provided by schools;
(K) Transportation used for
behavioral intervention or calming;
(L) Transportation normally
provided by a primary caregiver for a child of similar age without disabilities;
(M) Reimbursement for out-of-state
travel expenses; and
(N) Transportation services
that may be obtained through other means, such as OHP or other alternative resources
available to the child.
(16) TRANSITION COSTS.
(a) Transition costs are
limited to a child transitioning to the family home from a nursing facility or intermediate
care facility for individuals with intellectual or developmental disabilities.
(b) Transition costs are
based on the assessed need of a child determined during the person-centered service
planning process and must support the desires and goals of the child receiving services
and supports. Final approval for transition costs must be through the Department
prior to expenditure. The approval of the Department is based on the need of the
child and the determination by the Department of appropriateness and cost-effectiveness.
(c) Financial assistance
for transition costs is limited to:
(A) Moving and move-in costs
including movers, cleaning and security deposits, payment for background or credit
checks (related to housing), or initial deposits for heating, lighting, and phone;
(B) Payment of previous utility
bills that may prevent the child from receiving utility services and basic household
furnishings such as a bed; and
(C) Other items necessary
to re-establish a home.
(d) Transition costs are
provided no more than twice annually.
(e) Transitions costs for
basic household furnishings and other items are limited to one time per year.
(f) Transition costs may
not supplant the legal responsibility of the parent or guardian. In this context,
the term parent or guardian does not include a designated representative.
(17) FAMILY TRAINING. Family
training services are provided to the family of a child to increase the abilities
of the family to care for, support, and maintain the child in the family home.
(a) Family training services
include:
(A) Instruction about treatment
regimens and use of equipment specified in an ISP;
(B) Information, education,
and training about the disability, medical, and behavioral conditions of a child;
and
(C) Registration fees for
organized conferences and workshops specifically related to the disability of the
child or the identified, specialized, medical, or behavioral support needs of the
child.
(i) Conferences and workshops
must be prior authorized by a services coordinator, directly relate to the disability
or medical condition of a child, and increase the knowledge and skills of the family
to care for and maintain the child in the family home.
(ii) Conference and workshop,
costs exclude:
(I) Travel, food, and lodging
expenses;
(II) Services otherwise provided
under OHP or available through other resources; or
(III) Costs for individual
family members who are employed to care for the child.
(b) Family training services
exclude:
(A) Mental health counseling,
treatment, or therapy;
(B) Training for a paid provider;
(C) Legal fees;
(D) Training for a family
to carry out educational activities in lieu of school;
(E) Vocational training for
family members; and
(F) Paying for training to
carry out activities that constitute abuse of a child.
(18) ENVIRONMENTAL SAFETY
MODIFICATIONS.
(a) Environmental safety
modifications must be made from materials of the most cost effective type and may
not include decorative additions.
(b) Fencing may not exceed
200 linear feet without approval from the Department.
(c) Environmental safety
modifications exclude:
(A) Large gates such as automobile
gates;
(B) Costs for paint and stain;
(C) Adaptations or improvements
to the family home that are of general utility and are not for the direct medical
or remedial benefit to the child or do not address the underlying environmental
need for the modification; and
(D) Adaptations that add
to the total square footage of the family home.
(d) Environmental safety
modifications must be tied to supporting ADL, IADL, and health-related tasks as
identified in the ISP for the child.
(e) Environmental safety
modifications are limited to $5,000 per modification. A services coordinator must
request approval for additional expenditures through the Department prior to expenditure.
Approval is based on the service and support needs and goals of the child and a
determination by the Department of appropriateness and cost-effectiveness.
(f) In addition, separate
environmental safety modification projects that cumulatively total up to over $5,000
in a plan year must be submitted to the Department for review.
(g) Environmental safety
modifications must be completed by a state licensed contractor with a minimum of
$1,000,000 liability insurance. Any modification requiring a permit must be inspected
by a local inspector and certified as in compliance with local codes. Certification
of compliance must be filed in the file for the contractor prior to payment.
(h) Environmental safety
modifications must be made within the existing square footage of the family home
and may not add to the square footage of the family home.
(i) Payment to the contractor
is to be withheld until the work meets specifications.
(j) A scope of work as defined
in OAR 411-355-0010 must be completed for each identified environmental modification
project. All contractors submitting bids must be given the same scope of work.
(k) A services coordinator
must follow the processes outlined in the Expenditure Guidelines for contractor
bids and the awarding of work.
(l) All dwellings must be
in good repair and have the appearance of sound structure.
(m) The identified home may
not be in foreclosure or the subject of legal proceedings regarding ownership.
(n) Environmental modifications
must only be completed to the family home.
(o) Upgrades in materials
that are not directly related to the health and safety needs of the child are not
paid for or permitted.
(p) Environmental modifications
are subject to Department requirements regarding material and construction practices
based on industry standards for safety, liability, and durability, as referenced
in building codes, materials manuals, and industry and risk management publications.
(q) RENTAL PROPERTY.
(A) Environmental modifications
to rental property may not substitute or duplicate services otherwise the responsibility
of the landlord under the landlord tenant laws, the Americans with Disabilities
Act, or the Fair Housing Act.
(B) Environmental modifications
made to a rental structure must have written authorization from the owner of the
rental property prior to the start of the work.
(C) The Department does not
fund work to restore the rental structure to the former condition of the rental
structure.
(19) VEHICLE MODIFICATIONS.
(a) Vehicle modifications
may only be made to the vehicle primarily used by a child to meet the unique needs
of the child. Vehicle modifications may include a lift, interior alterations to
seats, head and leg rests, belts, special safety harnesses, other unique modifications
to keep the child safe in the vehicle, and the upkeep and maintenance of a modification
made to the vehicle.
(b) Vehicle modifications
exclude:
(A) Adaptations or improvements
to a vehicle that are of general utility and are not of direct medical benefit to
a child or do not address the underlying need for the modification;
(B) The purchase or lease
of a vehicle; or
(C) Routine vehicle maintenance
and repair.
(c) Vehicle modifications
are limited to $5,000 per modification. A services coordinator must request approval
for additional expenditures through the Department prior to expenditure. Approval
is based on the service and support needs and goals of the child and a determination
by the Department of appropriateness and cost-effectiveness. In addition, separate
vehicle modification projects that cumulatively total up to over $5,000 in a plan
year must be submitted to the Department for review.
(d) Vehicle modifications
must meet applicable standards of manufacture, design, and installation.
(20) SPECIALIZED MEDICAL
SUPPLIES. Specialized medical supplies do not cover services which are otherwise
available to a child under Vocational Rehabilitation and Other Rehabilitation Services,
29 U.S.C. 701-7961 as amended, or the Individuals with Disabilities Education Act,
20 U.S.C. 1400 as amended. Specialized medical supplies may not overlap with, supplant,
or duplicate other services provided through a waiver, OHP, or Medicaid state plan
services.
(21) SPECIAL DIET.
(a) A special diet is a supplement
and is not intended to meet the complete, daily nutritional requirements for a child.
(b) A special diet must be
ordered at least annually by a physician licensed by the Oregon Board of Medical
Examiners and periodically monitored by a dietician or physician.
(c) The maximum monthly purchase
for special diet supplies may not exceed $100 per month.
(d) Special diet supplies
must be in support of an evidence-based treatment regimen.
(e) A special diet excludes
restaurant and prepared foods and vitamins.
(22) INDIVIDUAL-DIRECTED
GOODS AND SERVICES.
(a) Individual-directed goods
and services provide equipment and supplies that are not otherwise available through
another source, such as waiver services, OHP, or Medicaid State Plan services.
(b) Individual-directed goods
and services are therapeutic in nature and must be recommended in writing by at
least one licensed health professional or by a behavior consultant.
(c) Individual-directed goods
and services must directly address an identified disability related need of a child
in the ISP.
(d) Individual-directed goods
and services must:
(A) Decrease the need for
other Medicaid services;
(B) Promote inclusion of
a child in the community; or
(C) Increase the safety of
a child in the family home.
(e) Individual-directed goods
and services may not be:
(A) Otherwise available through
another source, such as waiver services or state plan services;
(B) Experimental or prohibited
treatment;
(C) Goods or services that
are normally purchased by a family for a typically developing child of the same
age; or
(D) Purchased solely due
to the inability of the parent or guardian to pay for an item or service.
(f) Individual-directed goods
and services purchased must be the most cost effective option available to meet
the needs of the child.
(23) The assessed supports
as authorized by the Department in the ISP, dated from the initial ISP to the anniversary
date, must not be exceeded. Supports may increase or decrease in direct relationship
to the functional needs assessment.
(24) All MICP services authorized
by the Department must be included in a written ISP in order to be eligible for
payment. The ISP must use the most cost effective services for safely and appropriately
meeting the assessed needs of a child as determined by a services coordinator. Any
goods purchased with MICP funds that are not used according to an ISP may be immediately
recovered by the Department.
(25) All requests for General
Fund expenditures and expenditures exceeding limitations in the Expenditure Guidelines
must be authorized by the Department. The approval of the Department is limited
to 90 days unless re-authorized. A request for a General Fund expenditure or an
expenditure exceeding limitations in the Expenditure Guidelines is only authorized
in the following circumstances:
(a) The child is not safely
served in the family home without the expenditure;
(b) The expenditure provides
supports for emerging or changing service needs or behaviors of the child;
(c) A significant medical
condition or event, as documented by a primary caregiver, prevents or seriously
impedes the primary caregiver from providing services; or
(d) The services coordinator,
and if appropriate a behavior consultant, determines that the child needs two staff
present at one time to ensure the safety of the child and others. Prior to approval,
the services coordinator must determine that the caregiver, including the parent
or guardian, and where indicated, has been trained in behavior management and that
all other feasible recommendations from the behavior consultant and the services
coordinator have been implemented.
(26) Payment for CIIS is
made in accordance with the Expenditure Guidelines.
(27) The Department does
not pay for MICP services that are:
(a) Illegal, experimental,
or determined unsafe for the general public by a recognized child or consumer safety
agency;
(b) Notwithstanding abuse
as defined in ORS 419B.005, abusive, aversive, or demeaning;
(c) Not necessary, not in
accordance with the Expenditure Guidelines, not cost effective, or do not meet the
definition of support or social benefit as defined in OAR 411-355-0010;
(d) Educational services
for school-age children, including professional instruction, formal training, and
tutoring in communication, socialization, and academic skills;
(e) Services or activities
that the legislative or executive branch of Oregon government has prohibited use
of public funds;
(f) Medical treatments; or
(g) Provided by private health
insurance, OHP, or alternative resources.
Stat. Auth.: ORS 409.050, 417.345
Stats. Implemented: ORS 417.345,
427.007, 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 5-2010, f. 6-29-10,
cert. ef. 7-1-10; SPD 29-2013(Temp), f. & cert. ef. 7-2-13 thru 12-29-13; SPD
56-2013, f. 12-27-13, cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert. ef.
8-1-15 thru 1-27-16
411-355-0045
Standards for Employers
(1) EMPLOYER OF RECORD. An employer
of record is required when a personal support worker who is not an independent contractor
is selected by a parent or guardian to provide supports. The Department may not
act as the employer of record.
(2) SERVICE AGREEMENT. The
employer must create and maintain a service agreement for a personal support worker
that is in coordination with the services authorized in the ISP.
(3) BENEFITS. Only personal
support workers qualify for benefits. The benefits provided to personal support
workers are described in OAR chapter 411, division 375.
(4) INTERVENTION. For the
purpose of this rule, "intervention" means the action the Department or the designee
of the Department requires when an employer fails to meet the employer responsibilities
described in this rule. Intervention includes, but is not limited to:
(a) A documented review of
the employer responsibilities described in section (5) of this rule;
(b) Training related to employer
responsibilities;
(c) Corrective action taken
as a result of a personal support worker filing a complaint with the Department,
the designee of the Department, or other agency who may receive labor related complaints;
(d) Identifying an employer
representative if a person is not able to meet the employer responsibilities described
in section (5) of this rule; or
(e) Identifying another representative
if the current employer representative is not able to meet the employer responsibilities
described in section (5) of this rule.
(5) EMPLOYER RESPONSIBILITIES.
(a) For a child to be eligible
for MICP services provided by an employed personal support worker, an employer must
demonstrate the ability to:
(A) Locate, screen, and hire
a qualified personal support worker;
(B) Supervise and train the
personal support worker;
(C) Schedule work, leave,
and coverage;
(D) Track the hours worked
and verify the authorized hours completed by the personal support worker;
(E) Recognize, discuss, and
attempt to correct any performance deficiencies with the personal support worker
and provide appropriate, progressive, disciplinary action as needed; and
(F) Discharge an unsatisfactory
personal support worker.
(b) Indicators that an employer
may not be meeting the employer responsibilities described in subsection (a) of
this section include, but are not limited to:
(A) Personal support worker
complaints;
(B) Multiple complaints from
a personal support worker requiring intervention from the Department as defined
in section (4) of this rule;
(C) Frequent errors on timesheets,
mileage logs, or other required documents submitted for payment that results in
repeated coaching from the Department;
(D) Complaints to Medicaid
Fraud involving the employer; or
(E) Documented observation
by the Department of services not being delivered as identified in an ISP.
(c) The Department may require
intervention as defined in section (4) of this rule when an employer has demonstrated
difficulty meeting the employer responsibilities described in subsection (a) of
this section.
(d) A child may not receive
MICP services provided by a personal support worker if, after appropriate intervention
and assistance, an employer is not able to meet the employer responsibilities described
in subsection (a) of this section. The child may receive MICP services provided
by a provider organization or general business provider, when available.
(6) DESIGNATION OF EMPLOYER
RESPONSIBLITIES.
(a) A parent or guardian
not able to meet all of the employer responsibilities described in section (5)(a)
of this rule must:
(A) Designate an employer
representative in order for the child to receive or continue to receive MICP services
provided by a personal support worker; or
(B) Select a provider organization
or general business provider to provide MICP services.
(b) A parent or guardian
able to demonstrate the ability to meet some of the employer responsibilities described
in section (5)(a) of this rule must:
(A) Designate an employer
representative to fulfill the responsibilities the parent or guardian is not able
to meet in order for the child to receive or continue to receive MICP services provided
by a personal support worker; and
(B) On a Department approved
form, document the specific employer responsibilities to be performed by the parent
or guardian and the employer responsibilities to be performed by the employer representative.
(c) When an employer representative
is not able to meet the employer responsibilities described in section (5)(a) or
the qualifications in section (7)(c) of this rule, the parent or guardian must:
(A) Designate a different
employer representative in order for the child to receive or continue to receive
MICP services provided by a personal support worker; or
(B) Select a provider organization
or general business provider to provide MICP services.
(7) EMPLOYER REPRESENTATIVE.
(a) A parent or guardian
may designate an employer representative to act on behalf of the parent or guardian
to meet the employer responsibilities described in section (5)(a) of this rule.
(b) If a personal support
worker is selected by the parent or guardian to act as the employer, the parent
or guardian must seek an alternate employer for purposes of the employment of the
personal support worker. The alternate employer must:
(A) Track the hours worked
and verify the authorized hours completed by the personal support worker; and
(B) Document the specific
employer responsibilities performed by the employer on a Department-approved form.
(c) The Department may suspend,
terminate, or deny a request for an employer representative if the requested employer
representative has:
(A) A founded report of child
abuse or substantiated adult abuse;
(B) Participated in billing
excessive or fraudulent charges; or
(C) Failed to meet the employer
responsibilities in section (5)(a) or (7)(b) of this rule, including previous termination
as a result of failing to meet the employer responsibilities in section (5)(a) or
(7)(b) of this rule.
(d) If the Department suspends,
terminates, or denies a request for an employer representative for the reasons described
in subsection (c) of this section, the parent or guardian may select another employer
representative.
(8) NOTICE.
(a) The Department shall
mail a notice to the parent or guardian when:
(A) The Department denies,
suspends, or terminates an employer from performing the employer responsibilities
described in sections (5)(a) or (7)(b) of this rule; and
(B) The Department denies,
suspends, or terminates an employer representative from performing the employer
responsibilities described in section (5)(a) or (7)(b) of this rule because the
employer representative does not meet the qualifications in section (7)(c) of this
rule.
(b) If the parent or guardian
does not agree with the action taken by the Department, the parent or guardian may
request an administrator review.
(A) The request for an administrator
review must be made in writing and received by the Department within 45 days from
the date of the notice.
(B) The determination of
the Director is issued in writing within 30 days from the date the written request
for an administrator review was received by the Department.
(C) The determination of
the Director is the final response from the Department.
(c) When a denial, suspension,
or termination of an employer results in the Department denying, suspending, or
terminating a child from MFC services, the hearing rights in OAR chapter 411, division
318 apply.
Stat. Auth.: ORS 409.050, 417.345
Stats. Implemented: ORS 417.345,
427.007, 430.215
Hist.: APD 16-2015(Temp),
f. 7-30-15, cert. ef. 8-1-15 thru 1-27-16
411-355-0050
Standards for Providers Paid with MICP
Funds
(1) PERSONAL SUPPORT WORKERS. A personal
support worker must meet the qualifications described in OAR chapter 411, division
375.
(2) INDEPENDENT PROVIDERS
WHO ARE NOT PERSONAL SUPPORT WORKERS.
(a) An independent provider
who is not a personal support worker who is paid as a contractor or a self-employed
person and selected to provide MICP services must:
(A) Be at least 18 years
of age;
(B) Have approval to work
based on Department policy and a background check completed by the Department in
accordance with OAR 407-007-0200 to 407-007-0370. A subject individual as defined
in OAR 407-007-0210 may be approved for one position to work with multiple individuals
statewide when the subject individual is working in the same employment role. The
Background Check Request form must be completed by the subject individual to show
intent to work statewide;
(i) Prior background check
approval for another Department provider type is inadequate to meet background check
requirements for independent provider enrollment.
(ii) Background check approval
is effective for two years from the date an independent provider is contracted with
to provide in-home services, except in the following circumstances:
(I) Based on possible criminal
activity or other allegations against the independent provider, a new fitness determination
is conducted resulting in a change in approval status; or
(II) The background check
approval has ended because the Department has inactivated or terminated the provider
enrollment for the independent provider.
(C) Effective July 28, 2009,
not have been convicted of any of the disqualifying crimes listed in OAR 407-007-0275;
(D) Be legally eligible to
work in the United States;
(E) Not be the primary caregiver,
parent, adoptive parent, stepparent, spouse, or other person legally responsible
for the child receiving MICP services;
(F) Demonstrate by background,
education, references, skills, and abilities that he or she is capable of safely
and adequately performing the tasks specified in the ISP for the child, with such
demonstration confirmed in writing by the parent or guardian including:
(i) Ability and sufficient
education to follow oral and written instructions and keep any records required;
(ii) Responsibility, maturity,
exercising sound judgment, and reputable character;
(iii) Ability to communicate
with the parent or guardian;
(iv) Training of a nature
and type sufficient to ensure that the provider has knowledge of emergency procedures
specific to the child.
(G) Hold current, valid,
and unrestricted appropriate professional license or certification where services
and supervision requires specific professional education, training, and skill;
(H) Understand requirements
of maintaining confidentiality and safeguarding information about the child and
family;
(I) Not be on the list of
excluded or debarred providers maintained by the Office of Inspector General (http://exclusions.oig.hhs.gov/);
(J) If providing transportation,
a valid license to drive and proof of insurance, as well as any other license or
certification that may be required under state and local law depending on the nature
and scope of the transportation; and
(K) Sign a Medicaid provider
agreement and be enrolled as a Medicaid provider prior to delivery of any services.
(b) Subsection (1)(a)(C)
of this section does not apply to employees of a parent or guardian, employees of
a general business provider, or employees of a provider organization, who were hired
prior to July 28, 2009 and remain in the current position for which the employee
was hired.
(c) If a provider is an independent
contractor during the terms of a contract, the provider must maintain in force,
at the expense of the provider, professional liability insurance with a combined
single limit of not less than $1,000,000 for each claim, incident, or occurrence.
Professional liability insurance is to cover damages caused by error, omission,
or negligent acts related to the professional services.
(A) The provider must provide
written evidence of insurance coverage to the Department prior to beginning work
and at any time upon the request of the Department.
(B) There must be no cancellation
of insurance coverage without 30 days prior written notice to the Department.
(3) All providers must self-report
any potentially disqualifying condition as described in OAR 407-007-0280 and OAR
407-007-0290. The provider must notify the Department or the designee of the Department
within 24 hours.
(4) A provider must immediately
notify the parent or guardian and the services coordinator of injury, illness, accident,
or any unusual circumstance that may have a serious effect on the health, safety,
physical, emotional well-being, or level of service required by the child for whom
MICP services are being provided.
(5) All providers are mandatory
reporters and are required to report suspected child abuse to the local Department
office or to the police in the manner described in ORS 419B.010.
(6) Independent providers,
including personal support workers, are not employees of the state, CDDP, or Support
Services Brokerage.
(7) BEHAVIOR CONSULTANTS.
Behavior consultants are not personal support workers. Behavior consultants may
include, but are not limited to, autism specialists, licensed psychologists, or
other behavioral specialists. Behavior consultants providing specialized supports
must:
(a) Have education, skills,
and abilities necessary to provide behavior support services as described in OAR
411-355-0040;
(b) Have current certification
demonstrating completion of OIS training; and
(c) Submit a resume or the
equivalent to the Department indicating at least one of the following:
(A) A bachelor's degree in
special education, psychology, speech and communication, occupational therapy, recreation,
art or music therapy, or a behavioral science or related field, and at least one
year of experience with individuals who present difficult or dangerous behaviors;
or
(B) Three years of experience
with individuals who present difficult or dangerous behaviors and at least one year
of that experience includes providing the services of a behavior consultant as described
in OAR 411-355-0040.
(d) Additional education
or experience may be required to safely and adequately provide the services described
in OAR 411-355-0040.
(8) COMMUNITY NURSE. A nurse
providing community nursing services must be an enrolled Medicaid provider and meet
the qualifications in OAR 411-048-0210.
(9) DIETICIANS. Dieticians
providing specialized diets must be licensed according to ORS 691.415 through 691.465.
(10) PROVIDER ORGANIZATIONS
WITH CURRENT LICENSE OR CERTIFICATION.
(a) The following provider
organizations may not require additional certification as an organization to provide
relief care, attendant care, skills training, community transportation, or behavior
support services:
(A) 24-hour residential settings
certified, endorsed, and licensed under OAR chapter 411, division 325;
(B) Foster homes for children
certified under OAR chapter 411, division 346;
(C) Foster homes for adults
licensed under OAR chapter 411, division 360;
(D) Employment settings certified
and endorsed under OAR chapter 411, divisions 323 and 345; and
(E) Supported living settings
certified and endorsed under OAR chapter 411, divisions 323 and 328.
(b) Current license, certification,
or endorsement is considered sufficient demonstration of ability to:
(A) Recruit, hire, supervise,
and train qualified staff;
(B) Provide services according
to an ISP; and
(C) Develop and implement
operating policies and procedures required for managing an organization and delivering
services, including provisions for safeguarding individuals receiving services.
(c) Provider organizations
must assure that all people directed by the provider organization as employees,
contractors, or volunteers to provide services paid for with MICP funds meet the
standards for independent providers described in this rule.
(11) GENERAL BUSINESS PROVIDERS.
General business providers providing services to children paid with MICP funds must
hold any current license appropriate to operate required by the State of Oregon
or federal law or regulation. Services purchased with MICP funds must be limited
to those within the scope of the license of the general business provider. Licenses
for general business providers include, but are not limited to:
(a) For a home health agency,
a license under ORS 443.015;
(b) For an in-home care agency,
a license under ORS 443.315;
(c) For providers of environmental
modifications involving building modifications or new construction, a current license
and bond as a building contractor as required by either OAR chapter 812 (Construction
Contractor's Board) or OAR chapter 808 (Landscape Contractors Board), as applicable;
(d) For environmental modification
consultants, a current license as a general contractor as required by OAR chapter
812, including experience evaluating homes, assessing the needs of a child, and
developing cost-effective plans to make homes safe and accessible;
(e) For public transportation
providers, a business license, vehicle insurance in compliance with the laws of
the Department of Motor Vehicles, and operators with a valid license to drive;
(f) For vendors and medical
supply companies providing assistive devices, a current retail business license
and, if vending medical equipment, be enrolled as Medicaid providers through the
Division of Medical Assistance Programs;
(g) For providers of personal
emergency response systems, a current retail business license; and
(h) For vendors and supply
companies providing specialized diets, a current retail business license.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 2-2010(Temp),
f. & cert. ef. 3-18-10 thru 6-30-10; SPD 5-2010, f. 6-29-10, cert. ef. 7-1-10;
SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0060
Standards for Provider Organizations Paid
by the Department
(1) A provider organization may not
require additional certification to provide relief care, community inclusion, or
emergent services if they are licensed or certified as:
(a) Twenty-four hour residential
programs under OAR chapter 411, division 325;
(b) Foster homes for children
with intellectual or developmental disabilities under OAR chapter 411, division
346;
(c) Child care centers under
OAR chapter 414, division 300; or
(d) Organizational camps
under OAR chapter 333, division 030.
(2) Provider organizations
licensed or certified as described in section (1) of this rule may be considered
sufficient demonstration of ability to:
(a) Recruit, hire, supervise,
and train qualified staff;
(b) Provide services according
to an ISP; and
(c) Develop and implement
operating policies and procedures required for managing an organization and delivering
services, including provisions for safeguarding individuals receiving services.
(3) A provider organization
that wishes to enroll with the MICP must maintain and submit evidence upon initial
application and upon request by the Department the following:
(a) Current background checks
on each employee who shall be providing services in a family home showing that the
employee has no disqualifying criminal convictions, including crimes identified
in OAR 407-007-0275;
(b) Professional liability
insurance that meets the requirements of OAR 411-355-0050; and
(c) Any licensure required
of the agency by the state of Oregon or federal law or regulation.
(4) Provider organizations
must assure that all individuals directed by the provider organization
as employees, contractors, or volunteers to provide services paid for with MICP
funds meet standards for qualification of providers outlined in OAR 411-355-0050.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 427.007
& 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 5-2010, f. 6-29-10,
cert. ef. 7-1-10; SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; Suspended by APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0070
Standards for General Business Providers
Paid by the Department
General business providers providing
services to children paid with MICP funds must hold any current license appropriate
to operate required by the state of Oregon or federal law or regulation.
(1) Home health agencies
must be licensed under ORS 443.015.
(2) In-home care agencies
must be licensed under ORS 443.315.
(3) Public transportation
providers must be regulated according to established standards and private transportation
providers must have business license and drivers licensed to drive in Oregon.
(4) Vendors and medical supply
companies providing specialized medical equipment and supplies must have a current
retail business license and, if vending medical equipment, be enrolled as Medicaid
providers through the Division of Medical Assistance Programs.
(5) Providers of personal
emergency response systems must have a current retail business license.
(6) Vendors and supply companies
providing specialized diets must have a current retail business license.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; Suspended by APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0075
Provider Enrollment Inactivation and Termination
(1) PERSONAL SUPPORT WORKERS. The provider
enrollment for a personal support worker is inactivated or terminated as described
in OAR chapter 411, division 375.
(2) INDEPENDENT PROVIDERS
WHO ARE NOT PERSONAL SUPPORT WORKERS.
(a) The provider enrollment
for an independent provider who is not a personal support worker may be inactivated
in the following circumstances:
(A) The provider has not
provided any paid services to a child within the last previous 12 months;
(B) The provider informs
the Department, CDDP, MICP, or Support Services Brokerage that the provider is no
longer providing services in Oregon;
(C) The background check
for the provider results in a closed case pursuant to OAR 407-007-0325;
(D) The actions of the provider
are being investigated by adult or child protective services for suspected abuse
that poses imminent danger to current or future children; or
(E) Payments to the provider,
either whole or in part, for the provider have been suspended based on a credible
allegation of fraud or has a conviction of fraud pursuant to federal law under 42
CFR 455.23.
(b) The enrollment for an
independent provider, who is not a personal support worker, may be terminated when
the Department determines after enrollment that the independent provider has:
(A) Been convicted of any
crime that would have resulted in an unacceptable background check upon hiring or
authorization of service;
(B) Been convicted of unlawfully
manufacturing, distributing, prescribing, or dispensing a controlled substance;
(C) Surrendered his or her
professional license or had his or her professional license suspended, revoked,
or otherwise limited;
(D) Failed to safely and
adequately provide the authorized services;
(E) Had a founded report
of child abuse or substantiated adult abuse;
(F) Failed to cooperate with
any Department or CDDP investigation or grant access to, or furnish, records or
documentation, as requested;
(G) Billed excessive or fraudulent
charges or been convicted of fraud;
(H) Made a false statement
concerning conviction of a crime or substantiated abuse;
(I) Falsified required documentation;
(J) Been suspended or terminated
as a provider by the Department or Oregon Health Authority;
(K) Violated the requirement
to maintain a drug-free work place;
(L) Failed to provide services
as required;
(M) Failed to provide a tax
identification number or social security number that matches the legal name of the
independent provider, as verified by the Internal Revenue Service or Social Security
Administration; or
(N) Been excluded or debarred
by the Office of the Inspector General.
(c) If the Department makes
a decision to terminate the provider enrollment of an independent provider who is
not a personal support worker, the Department must issue a written notice. The written
notice must include:
(A) An explanation of the
reason for termination of the provider enrollment;
(B) The alleged violation
as listed in subsection (A) or (B) of this section; and
(C) The appeal rights for
the independent provider, including how to file an appeal.
(d) For terminations based
on substantiated abuse allegations, the notice may only contain the limited information
allowed by law. In accordance with ORS 124.075, 124.085, 124.090, and OAR 411-020-0030,
complainants, witnesses, the name of the alleged victim, and protected health information
may not be disclosed.
(e) The provider may appeal
a termination within 30 days from the date the termination notice was mailed to
the provider. The provider must appeal a termination separately from any appeal
of audit findings and overpayments.
(A) A provider of Medicaid
services may appeal a termination by requesting an administrator review.
(B) For an appeal regarding
provision of Medicaid services to be valid, written notice of the appeal must be
received by the Department within 30 days from the date the termination notice was
mailed to the provider.
(f) At the discretion of
the Department, providers who have previously been terminated or suspended by the
Department or by the Oregon Health Authority may not be authorized as providers
of Medicaid services.
Stat. Auth.: ORS 409.050, 417.345
Stats. Implemented: ORS 417.345,
427.007, 430.215
Hist.: APD 16-2015(Temp),
f. 7-30-15, cert. ef. 8-1-15 thru 1-27-16
411-355-0080
MICP Documentation Needs
(1) Accurate timesheets of MICP services
must be dated and signed by the provider and the parent or guardian of the child
after the services are provided. Timesheets must be maintained and submitted to
the Department with any request for payment for services.
(2) Requests for payment
for MICP services must:
(a) Include the billing form
indicating prior authorization for the services;
(b) Be signed by the provider
acknowledging agreement with the terms and condition of the billing form and attesting
that the hours were delivered as billed; and
(c) Be signed by the parent
or guardian of the child after the services were delivered, verifying that the services
were delivered as billed.
(3) Documentation of MICP
services provided must be provided to the services coordinator upon request or as
outlined in the ISP for the child and maintained in the family home or the place
of business of the provider of services. The Department does not pay for services
that are not outlined in the ISP for the child or unrelated to the disability of
the child.
(4) The Department retains
billing forms and timesheets for at least five years from the date of service.
(5) Behavior consultants
must submit the following to the Department written in clear, concrete language,
understandable to the parent or guardian of the child and the provider:
(a) An evaluation of the
child, the concerns of the parent or guardian, the environment of the child, current
communication strategies used by the child and used by others with the child, and
any other disability of the child that may impact the appropriateness of strategies
to be used with the child; and
(b) Any behavior plan or
instructions left with the parent or provider that describes the suggested strategies
to be used with the child.
(6) A Nursing Service Plan
must be developed within seven days of the initiation of MICP services and submitted
to the Department for approval when services which require nursing delegation are
provided.
(a) The Nursing Service Plan
must be reviewed, updated, and resubmitted to the Department in the following instances:
(A) Every six months;
(B) Within seven working
days of a change of the nurse who writes the Nursing Service Plan;
(C) With any request for
authorization of an increase in hours of service; or
(D) After any significant
change of condition, such as hospital admission or change in health status.
(b) The provider must share
the Nursing Service Plan with the parent or guardian.
(7) The Department must be
notified by the provider or the primary caregiver within one working day of the
hospitalization or death of any eligible child.
(8) Providers must maintain
documentation of provided services for at least seven years from the date of service.
If a provider is a nurse, the nurse must either maintain documentation of provided
services for at least five years or send the documentation to the Department.
(9) Providers must furnish
requested documentation immediately upon the written request from the Department,
the Oregon Department of Justice Medicaid Fraud Unit, Centers for Medicare and Medicaid
Services, or their authorized representatives, and within the time frame specified
in the written request. Failure to comply with the request may be considered by
the Department as reason to deny or recover payments.
(10) Access to records by
the Department, including but not limited to, medical, nursing, behavior, psychiatric,
or financial records, to include providers and vendors providing goods and services,
does not require authorization or release by the child or the parent or guardian
of the child.
Stat. Auth.: ORS 409.050, 417.345
Stats. Implemented: ORS 417.345,
427.007, 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0090
Payment for MICP Services
(1) Payment is made after MICP services
are delivered as authorized.
(2) Effective July 28, 2009,
MICP funds may not be used to support, in whole or in part, a provider in any capacity
who has been convicted of any of the disqualifying crimes listed in OAR 407-007-0275.
(3) Section (2) of this rule
does not apply to an employee of a parent or guardian or a provider who was hired
prior to July 28, 2009 that remains in the current position for which the employee
was hired.
(4) Payment for MICP services
is made in accordance with the Expenditure Guidelines.
(5) Service levels are based
on the individual needs of a child as identified by a functional needs assessment
and medically involved criteria and authorized in the ISP for the child.
(6) Authorization must be
obtained prior to the delivery of any MICP services for the services to be eligible
for payment.
(7) A providers must request
payment authorization for MICP services provided during an unforeseeable emergency
on the first business day following the emergency service. A services coordinator
must determine if the service is eligible for payment.
(8) The Department makes
payment to the employee of a parent or guardian on behalf of the parent or guardian.
The Department pays the employer's share of the Federal Insurance Contributions
Act tax (FICA) and withholds FICA as a service to the parent or guardian, who is
the employer.
(9) The delivery of authorized
MICP services must occur so that any individual employee of the parent or guardian
does not exceed 40 hours per work week. The Department does not authorize services
that require the payment of overtime without prior written authorization by the
supervisor of children's intensive in-home services.
(10) Holidays are paid at
the same rate as non-holidays.
(11) Travel time to reach
the job site is not reimbursable.
(12) Payment by the Department
for MICP services is considered full payment for the services rendered under Medicaid.
A provider may not demand or receive additional payment for MICP services from the
parent, guardian, or any other source, under any circumstances.
(13) Medicaid funds are the
payor of last resort. A provider must bill all third party resources until all third
party resources are exhausted.
(14) The Department reserves
the right to make a claim against any third party payer before or after making payment
to the provider.
(15) The Department may void
without cause prior authorizations that have been issued in the event of any of
the following:
(a) Change in the status
of the child, such as hospitalization, improvement in health status, or death of
the child;
(b) Decision of the parent
or guardian to change providers;
(c) Inadequate services,
inadequate documentation, or failure to perform other expected duties;
(d) Documentation of a person
who is subject to background checks on or after July 28, 2009, as required by administrative
rule, has been convicted of any of the disqualifying crimes listed in OAR 407-007-0275;
or
(e) Any situation, as determined
by the services coordinator that puts the health or safety of the child at risk.
(16) Section (15)(d) of this
rule does not apply to employees of parents or guardians or billing providers who
were hired prior to July 28, 2009 that remain in the current position for which
the employee was hired.
(17) Upon submission of the
billing form for payment, a provider must comply with:
(a) All rules in OAR chapter
407 and OAR chapter 411;
(b) 45 CFR Part 84 that implements
Title V, Section 504 of the Rehabilitation Act of 1973 as amended;
(c) Title II and Title III
of the Americans with Disabilities Act of 1991; and
(d) Title VI of the Civil
Rights Act of 1964.
(18) All billings must be
for MICP services provided within the licensure and certification of the provider.
(19) The provider must submit
true and accurate information on the billing form. Use of a provider organization
does not replace the responsibility of the provider for the truth and accuracy of
submitted information.
(20) A person may not submit
the following to the Department:
(a) A false billing form
for payment;
(b) A billing form for payment
that has been, or is expected to be, paid by another source; or
(c) Any billing form for
MICP services that have not been provided.
(21) The Department only
makes payment to an enrolled provider who actually performs the MICP services or
the enrolled provider organization. Federal regulations prohibit the Department
from making payment to a collection agency.
(22) Payment is denied if
any provisions of these rules are not complied with.
(23) The Department recoups
all overpayments.
(a) The amount to be recovered:
(A) Is the entire amount
determined or agreed to by the Department;
(B) Is not limited to the
amount determined by criminal or civil proceedings; and
(C) Includes interest to
be charged at allowable state rates.
(b) A request for repayment
of the overpayment or notification of recoupment of future payments is delivered
to the provider by registered or certified mail or in person.
(c) Payment schedules with
interest may be negotiated at the discretion of the Department.
(d) If recoupment is sought
from a parent or guardian, the parent or guardian has the right to request a hearing
as provided in ORS chapter 183.
(24) The Department makes
payment for MICP services after services are delivered as authorized in the ISP
for the child and required documentation is received by the services coordinator.
(25) In order to be eligible
for payment, requests for payments must be submitted to the Department within 12
months of the delivery of MICP services.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 2-2010(Temp),
f. & cert. ef. 3-18-10 thru 6-30-10; SPD 5-2010, f. 6-29-10, cert. ef. 7-1-10;
SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0100
Rights, Complaints, Notification of Planned
Action, and Hearings
(1) RIGHTS OF A CHILD.
(a) The rights of a child
are described in OAR 411-318-0010.
(b) Upon entry and request
and annually thereafter, the individual rights described in OAR 411-318-0010 must
be provided to the parent or guardian and the child.
(2) COMPLAINTS.
(a) Complaints must be addressed
in accordance with OAR 411-318-0015.
(b) Upon entry and request
and annually thereafter, the policy and procedures for complaints as described in
OAR 411-318-0015 must be explained and provided to the parent or guardian of each
child.
(3) NOTIFICATION OF PLANNED
ACTION. In the event MICP services are denied, reduced, suspended, or terminated,
a written advance Notification of Planned Action (form SDS 0947) must be provided
as described in OAR 411-318-0020.
(4) HEARINGS.
(a) Hearings must be addressed
in accordance with ORS chapter 183 and OAR 411-318-0025.
(b) The parent or guardian
may request a hearing as provided in ORS chapter 183 and OAR 411-318-0025.
(c) Upon entry and request
and annually thereafter, a notice of hearing rights and the policy and procedures
for hearings as described in OAR chapter 411, division 318 must be explained and
provided to the parent or guardian of each child.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0110
Denial, Termination, Suspension, Reduction
or Eligibility for MICP Services for Individual Medicaid Recipients
(1) MEDICAID FAIR HEARING RIGHTS. Each
time the Department takes an action to deny, terminate, suspend, or reduce a child’s
access to services covered under Medicaid, the Department shall notify the child’s
parent of the right to a hearing and the method to request a hearing. The Department
shall mail the notice by certified mail, or personally serve it to the child’s
parent 10 days or more prior to the effective date of an action.
(a) The Department shall
use, Notice of Hearing Rights, or a comparable Department-approved form for such
notification. This notification requirement does not apply if an action is part
of, or fully consistent with, the ISP, or the child’s parent has agreed with
the action by signature to the ISP. The notice shall be given directly to the parent
when the ISP is signed.
(b) The parent may appeal
a denial of a request for additional or different services only if the request has
been made in writing and submitted to the address on the notice to expedite the
process.
(c) A notice required by
section (1) of this rule must include:
(A) The action the Department
intends to take;
(B) The reasons for the intended
action;
(C) The specific Oregon Administrative
Rules that supports, or the change in federal or state law that requires, the action;
(D) The appealing party’s
right to request a hearing in accordance with OAR chapter 137, Oregon Attorney General’s
Model Rules, ORS chapter 183, and 42 CFR Part 431, Subpart E;
(E) A statement that the
Department files on the subject of the hearing automatically becoming part of the
hearing record upon default for the purpose of making a prima facie case;
(F) A statement that the
actions specified in the notice shall take effect by default if the Department representative
does not receive a request for hearing from the party within 45 days from the date
that the Department mails the notice of action;
(G) In cases of an action
based upon a change in law, the circumstances under which a hearing shall be granted;
and
(H) An explanation of the
circumstances under which MICP services shall be continued if a hearing is requested.
(d) If the parent disagrees
with the decision or proposed action of the Department to deny, terminate, suspend,
or reduce a child’s access to services covered under Medicaid, the parent
may request a hearing as provided in ORS chapter 183. The request for a hearing
must be in writing on Form DHS 443 and signed by the parent. The signed form (DHS
443) must be received by the Department within 45 days from the date of the Department’s
notice of denial.
(e) The parent may request
an expedited hearing if the parent feels that there is immediate, serious threat
to the child’s life or health should the normal timing of the hearing process
be followed.
(f) If the parent requests
a hearing before the effective date of the proposed actions and requests that the
existing services be continued, the Department shall continue the services.
(A) The Department must continue
the services until whichever of the following occurs first:
(i) The current authorization
expires;
(ii) The administrative law
judge issues a proposed order and the Department issues a final order; or
(iii) The child is no longer
eligible for Medicaid benefits.
(B) The Department must notify
the child’s parent that the Department is continuing the service. The notice
must inform the parent that, if the hearing is resolved against the child, the Department
may recover the cost of any services continued after the effective date of the continuation
notice.
(g) The Department may reinstate
services if:
(A) The Department takes
an action without providing the required notice and the parent requests a hearing;
(B) The Department fails
to provide the notice in the time required in this rule and the parent requests
a hearing within 10 days of the mailing of the notice of action; or
(C) The post office returns
mail directed to the parent, but the location of the parent becomes known during
the time that the child is still eligible for services.
(h) The Department must promptly
correct the action taken up to the limit of the original authorization, retroactive
to the date the action was taken, if the hearing decision is favorable to the child,
or the Department decides in the child’s favor before the hearing.
(i) The Department representative
and the parent may have an informal conference, without the presence of the administrative
law judge, to discuss any of the matters listed in OAR 137-003-0575. The informal
conference may also be used to:
(A) Provide an opportunity
for the Department and the parent to settle the matter;
(B) Ensure the child’s
parent understands the reason for the action that is the subject of the hearing
request;
(C) Give the parent an opportunity
to review the information that is the basis for that action;
(D) Inform the parent of
the rules that serve as the basis for the contested action;
(E) Give the parent and the
Department the chance to correct any misunderstanding of the facts;
(F) Determine if the parent
wishes to have any witness subpoenas issued; and
(G) Give the Department an
opportunity to review its action.
(j) The child’s parent
may, at any time prior to the hearing date, request an additional conference with
the Department representative. At the Department representative’s discretion,
the Department representative may grant an additional conference if it facilitates
the hearing process.
(k) The Department may provide
the parent the relief sought at any time before the final order is issued.
(l) A parent may withdraw
a hearing request at any time prior to the issuance of a final order. The withdrawal
shall be effective on the date the Department or the Office of Administrative Hearings
receives it. The Department must issue a final order confirming the withdrawal to
the last known address of the child’s parent. The child’s parent may
cancel the withdrawal up to 10 working days following the date the final order is
issued.
(2) PROPOSED AND FINAL ORDERS.
(a) In a contested case,
the administrative law judge must serve a proposed order on the child and the Department.
(b) If the administrative
law judge issues a proposed order that is adverse to the child, the child’s
parent may file exceptions to the proposed order to be considered by the Department.
The exceptions must be in writing and must be received by the Department no later
than 10 days after service of the proposed order. The child’s parent may not
submit additional evidence after this period unless the Department grants prior
approval.
(c) After receiving the exceptions,
if any, the Department may adopt the proposed order as the final order or may prepare
a new order. Prior to issuing the final order, the Department may issue an amended
proposed order.
(3) The performing or billing
provider must submit relevant documentation to the Department within five working
days at the request of the Department when a hearing has been requested.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; Suspended by APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16
411-355-0120
Sanctions for MICP Providers
(1) Sanctions may be imposed on a provider
when any of the following conditions is determined by the Department to have occurred:
(a) The provider has been
convicted of any crime that would have resulted in an unacceptable background check
upon hiring or issuance of a provider number;
(b) The provider has been
convicted of unlawfully manufacturing, distributing, prescribing, or dispensing
a controlled substance;
(c) The provider’s
license has been suspended, revoked, otherwise limited, or surrendered;
(d) The provider has failed
to safely and adequately provide the MICP services authorized as determined by the
parent or the services coordinator;
(e) The provider has had
a founded report of child abuse or substantiated abuse;
(f) The provider has failed
to cooperate with any investigation or grant access to or furnish, as requested,
records or documentation;
(g) The provider has billed
excessive or fraudulent charges or has been convicted of fraud;
(h) The provider has made
a false statement concerning conviction of crime or substantiation of abuse;
(i) The provider has falsified
required documentation;
(j) The provider has not
adhered to the provisions of these rules; or
(k) The provider has been
suspended or terminated as a provider by the Department or the Oregon Health Authority.
(2) The Department may impose
the following sanctions on a provider:
(a) Termination from participation
in the MICP;
(b) Suspension from participation
in the MICP for a specified length of time or until specified conditions for reinstatement
are met and approved by the Department; or
(c) Payments to the provider
may be withheld.
(3) If the Department makes
a decision to sanction a provider, the provider must be notified by mail of the
intent to sanction.
(a) The provider may appeal
a sanction by requesting an administrative review by the Department’s director.
(b) For an appeal to be valid,
written notice of the appeal must be received by the Department within 45 days of
the date the sanction notice was mailed to the provider.
(c) The provider must appeal
a sanction separately from any appeal of audit findings and overpayments.
(4) At the discretion of
the Department, providers who have previously been terminated or suspended by the
Department or the Oregon Health Authority may not be re-enrolled as providers of
Medicaid services.
Stat. Auth.: ORS 409.050 & 417.345
Stats. Implemented: ORS 417.345,
427.007 & 430.215
Hist.: SPD 5-2008(Temp),
f. & cert. ef. 4-15-08 thru 10-12-08; SPD 14-2008, f. & cert. ef 10-9-08;
SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 5-2010, f. 6-29-10,
cert. ef. 7-1-10; SPD 56-2013, f. 12-27-13, cert. ef. 12-28-13; Suspended by APD 16-2015(Temp), f. 7-30-15, cert.
ef. 8-1-15 thru 1-27-16

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