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DEPARTMENT OF HUMAN SERVICES,

AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES




 

DIVISION 18
ESSENTIAL COMMUNITY PROVIDER CERTIFICATION

411-018-0000
Purpose and Definitions
Purpose: These rules establish standards and procedures for a long-term care facility that will be certified by the Department as an essential community provider long-term care facility.
(1) "Adult Foster Home" defined in ORS 443.705 means any family home or facility in which residential care is provided in a home like environment for five or fewer adults who are not related to the provider by blood or marriage.
(2) "Certification" means a written statement by the Department that the facility is an essential community provider long-term care facility.
(3) "Department" means the Department of Human Services, Seniors and People with Disabilities Division.
(4) "Disqualification" means a written statement by the Department that informs the facility of the reasons for disqualification.
(5) "Essential community provider long-term care facility" means a long-term care facility in which the average residency rate is 50% or more eligible for Medicaid during the calendar year immediately preceding the calendar year in which the Department is making certification; except that in adult foster homes the average residency rate will be 60%.
(6) "Long term care facility" means a nursing facility, assisted living facility, residential care facility or an adult foster home that is licensed by the Department.
(7) "Medicaid" means Title XIX of the Social Security Act.
(8) "Medicaid eligible residency rate" means the days of facility occupancy in the calendar year for which Medicaid is responsible for payment either paid or accrued (or would have been paid by or accrued to Medicaid except that another payment source was available and used) divided by all days of facility occupancy in the calendar year for which payment has been made or a liability for payment accrued.
(9) "Medicare" means Title XVIII of the Social Security Act.
Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 307.808 - 307.815, 443.888 & 410.070

Hist.: SDSD 11-1999, f. 12-30-99 cert. ef. 1-1-00; SDSD 7-2000, f. 12-29-00 cert. ef. 1-1-01; SPD 17-2005, f. & cert. ef. 12-12-05
411-018-0010
Certification Process
(1) A long-term care facility seeking certification as an essential community provider long-term care facility must make written application to the Department. The application must include:
(a) The name under which the facility is licensed;
(b) The facility's Medicaid provider number, if the facility has a Medicaid contract;
(c) The mailing address of the facility;
(d) The county in which the facility is located;
(e) The name and address of a contact person at the facility;
(f) Information about facility residency during the previous calendar year to include:
(A) A monthly count of resident days paid for or accrued by Medicaid;
(B) A monthly count of resident days paid for or accrued by Medicare;
(C) A monthly count of resident days that would have been paid by Medicaid except for the availability of Medicare payment;
(D) A monthly count of resident days paid privately by facility residents or their families; and
(E) A monthly count of resident days paid through any other payment source; and
(g) A statement of the average calendar year Medicaid eligible residency rate. The average Medicaid eligible residency rate is the sum of all monthly days paid by or accrued to Medicaid plus all monthly days that would have been paid by Medicaid except for the availability and use of another source of payment divided by the total of all monthly days paid through or accrued to all payment sources including Medicaid. The percent calculated will be rounded up by the third decimal place.
(2) The Department will make a suggested application form available to facilities upon request. Facilities are not required to use the suggested application form to apply for certification; however, no application for certification may be considered complete until all information listed in section (1) of this rule is received.
(3) Applications must be delivered to Seniors and People with Disabilities, Research, Planning and Rate Setting, 500 Summer Street NE-E18, Salem, OR 97301-1074.
(4) The earliest date on which the Department will accept an application for certification is January 2 of the calendar year following the year for which the Certification is sought.
(5) Application will be considered complete on the date received by the Department if all required information is included.
(6) The Department must audit and review applications submitted by facilities to ensure accuracy of the information provided and will issue Certification if the average Medicaid eligible residency rate during the preceding calendar year is:
(a) 50 percent or more in a nursing facility, assisted living facility or residential care facility; or
(b) 60 percent or more in an adult foster home.
(7) The Department must issue a notice of Certification within 15 business days following receipt of the completed application if it is determined the facility meets the required Medicaid eligible residency rate in section (6)(a) or (6)(b) of this rule.
(8) The Certification issued by the Department will include information required by the local taxing districts for submitting Certifications.
(9) The Certification must be mailed to the mailing address supplied by the facility.
(10) The Certification issued by the Department only applies to the single licensed facility for which Certification is requested.
Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 307.808 - 307.815, 443.888 & 410.070

Hist.: SDSD 11-1999, f. 12-30-99 cert. ef. 1-1-00; SDSD 7-2000, f. 12-29-00 cert. ef. 1-1-01; SPD 17-2005, f. & cert. ef. 12-12-05
411-018-0020
Appeal Process
(1) The Department will issue a notice of Disqualification to a facility when it has been determined the facility does not qualify for Certification.
(2) The notice of Disqualification must be issued within 15 business days following receipt of the completed application and informs the facility of the reasons for disqualification. A facility is entitled to an informal conference or a contested case hearing pursuant to ORS 183.413-183.470, as described in sections (3) or (4) of this rule, to protest the disqualification.
(3) Informal Conference.
(a) The facility may request an informal conference by notifying the Department in writing within 30 days of receipt of the notice of Disqualification.
(b) The request for an informal conference must be postmarked within the 30-day limit and must state specifically the reasons for requesting the conference.
(c) The facility may submit documentation and explain the basis for the protest at the informal conference.
(d) Following the informal conference, the Department will notify the facility of its decision by mail within 15 business days.
(e) No judicial review is available following a decision from an informal conference. If the facility is not satisfied with the decision, the facility may request a contested case hearing pursuant to ORS 183.413-183.470 by notifying the Department in writing of the request for the hearing within 10 business days of the date of the decision notice from the informal conference.
(f) If a facility is not satisfied with the results from the contested case hearing, the facility may petition for judicial review pursuant to ORS 183.480-183.497.
(4) Contested Case Hearing.
(a) As an alternative to section (3) of this rule, the facility may request a contested case hearing pursuant to ORS 183.413-183.470 by notifying the Department in writing that a contested case hearing is requested, within 30 days of receipt of the notice of disqualification from the Department.
(b) The request for the contested case hearing must be postmarked within the 30-day limit and must state, specifically, the reason(s) for requesting the hearing.
(c) If a facility is not satisfied with the results from the contested case hearing, the facility may petition for judicial review pursuant to ORS 183.480-183.497.
(5) If no request for an informal conference or contested case hearing is made within the specified time period, the most recent decision from the Department automatically becomes the final order.
(6) A facility may request documentation supporting the disqualification from the Department; however, a request for documentation does not extend the time period within which an informal conference or contested case must be requested. The Department will produce these work papers within 30 days of receipt of a written request.
Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 307.808 - 307.815, 443.888 & 410.070

Hist.: SDSD 11-1999, f. 12-30-99 cert. ef. 1-1-00; SPD 17-2005, f. & cert. ef. 12-12-05

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