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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 172
MEDICAID PAYMENT FOR BEHAVIORAL
HEALTH SERVICES
410-172-0600
Acronyms and Definitions
(1) “ASAM PPC” means the
most current publication of the American Society of Addiction Medicine Patient Placement
Criteria for the Treatment of Substance-related Disorders, which is a clinical guide
used in matching individuals to appropriate levels of care.
(2) “Behavioral Health”
means mental health, mental illness, addiction disorders, and substance use disorders.
(3) “Behavioral Health
Services” means medically appropriate services rendered or made available
to a recipient for treatment of a behavioral health or substance use disorders diagnosis.
(4) “Community Mental
Health Program (CMHP)” means an entity that is responsible for planning and
delivery of services for persons with substance use disorders or a mental health
diagnosis, operated in a specific geographic area of the state under an intergovernmental
agreement or direct contract with the Division as defined in OAR 309-019-0105.
(5) “Letter”
means the document awarded to providers by AMH indicating the provider has complied
with specific program requirements or administrative rule.
(6) “Level of Care”
means the type, frequency, and duration of medically appropriate services provided
to a recipient of behavioral health services.
(7) “Level of Care
Determination” means the standardized process implemented to establish the
type, frequency, and duration of medically appropriate services required to treat
a diagnosed behavioral health condition.
(8) “Recovery Assistant”
means a provider who provides a flexible range of services. Recovery assistants
provide face-to-face services in accordance with a service plan that enables a participant
to maintain a home or apartment, encourages the use of existing natural supports,
and fosters involvement in treatment, social, and community activities. A recovery
assistant shall:
(a) Be at least 18 years
old;
(b) Meet the background check
requirements described in OAR 410-180-0326;
(c) Conform to the standards
of conduct as described in OAR 410-180-0340.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0610
Provider Enrollment
(1) Providers shall be enrolled with
the Division as a behavioral health provider. Paid providers of behavioral health
services shall possess a current and valid license, letter, or certificate.
(2) Providers shall provide
services within the scope of professional standards and practice defined by the
providers licensing board or certifying organization.
(3) Providers shall meet
all requirements in OAR 410-120-1260 (Medical Assistance Programs Provider Enrollment),
OAR 943-120-0310 (Provider Requirements), and OAR 943-120-0320 (Provider Enrollment).
(4) Providers shall not be
included on any US Office of Inspector General Exclusion lists.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0620
Documentation Standards
(1) OHP providers shall maintain records
that fully support the extent of services for which payment has been requested and
provide the records to the Division upon request.
(2) All records shall document
the specific service provided, the number of services comprising the service provided,
the extent of the service provided, the dates on which the service was provided,
and the individual who provided the service.
(3) Clinical records shall
document the recipient’s diagnosis and the medical need for the service.
(4) The record shall be annotated
each time a service is provided and be signed or initialed by the individual providing
the service.
(5) Information contained
in the record shall be appropriate in quality and quantity to meet the professional
standards applicable to the provider and any additional standards for documentation
found in these rules, other Division rules, and pertinent contracts.
(6) For AMH certified providers,
in addition to meeting the requirements in this rule, clinical documentation for
behavioral health services shall also comply with the requirements in OAR 309-019-0135
through OAR 309-019-0140, and clinical documentation standards for substance use
disorder services shall comply with OAR 309-018-0140 through OAR 309-018-0150.
Stat. Auth.: ORS 413.042, 430.640, 430.705,
& 430.715
Stats. Implemented: ORS 414.025,
414.065, & 430.640
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0630
Medically Appropriate
(1) In addition to the definition of
medically appropriate in OAR 410-120-0000 for behavioral health services, “medically
appropriate” means the services and supports required to diagnose, stabilize,
care for, and treat a behavioral health condition.
(2) The Division shall make
payment for medically appropriate behavioral health services when the services or
supports are:
(a) Rendered by a provider
whose training, credentials, or license is appropriate to treat the identified condition
and deliver the service;
(b) Based on the standards
of evidence-based practice, and the services provided are appropriate and consistent
with the diagnosis identified in the behavioral health assessment;
(c) Provided in accordance
with an individualized service plan and appropriate to achieve the specific and
measurable goals identified in the service plan;
(d) Not provided solely for
the convenience of the recipient, the recipient’s family, or the provider
of the services or supplies;
(e) Not provided solely for
recreational purposes;
(f) Not provided solely for
research and data collection;
(g) Not provided solely for
the purpose of fulfilling a legal requirement placed on the recipient.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0640
Behavioral Health Services Fee Schedule
(1) The Division shall pay providers
based on the Behavioral Health Services Fee Schedule (fee-for-service (FFS) payment
rates for behavioral health services) posted on the Authority web site.
(2) Payment shall be made
at each provider’s usual and customary charge or the Division’s published
reimbursement upper payment limit, whichever is less, minus payments received or
due from other payers. Payments to other specified providers shall be made according
to other approved schedules.
(3) The Division’s
maximum allowable rate-setting process uses a methodology that is based on the existing
Medicaid fee schedule with adjustments for legislative changes and payment levels.
(4) Limitations contained
in the Behavioral Health Services Fee Schedule, such as the maximum rate and the
amount, duration, and scope of services provided, are subject to change at the discretion
of the Division. Updates and changes are posted on the Behavioral Health Services
Fee Schedule website at www.oregon.gov/oha/healthplan/pages/feeschedule.aspx.
(5) Payment shall be made
for services listed in the Medicaid Behavioral Health Procedure Fee Schedule that
are rendered to Medicaid-eligible individuals by a qualified provider during the
period in which the provider is enrolled with the Division.
(6) For cost-reimbursed services,
the provider shall maintain adequate records to thoroughly explain how the amounts
reported on the cost statement were determined. The records shall be accurate and
in sufficient detail to substantiate the data reported. Providers whose rates are
paid based on a collective bargaining agreement are not exempt from this requirement.
(7) In accordance with 42
CFR ¦ 405.506, a charge that exceeds the customary charge of the physician
or other person who rendered the medical or other health service, or the prevailing
charge in the locality, or an applicable lowest charge level may be found to be
reasonable, but only where there are unusual circumstances, or medical complications
requiring additional time, effort, or expense that support an additional charge,
and only if it is acceptable medical or medical service practice in the locality
to make an extra charge in such cases. The mere fact that the physician’s
or other person’s customary charge is higher than prevailing would not justify
a determination that it is reasonable.
(8) Payment by the Division
does not limit the Authority or any state or federal oversight entity from reviewing
or auditing a claim before or after the payment. Payment may be denied or subject
to recovery if medical review, audit, or other post-payment review determines that
payment for the service was not provided in accordance with applicable Oregon Administrative
Rules or the service does not meet the criteria for quality or medical appropriateness
of the care.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0650
Prior Authorization
(1) Some services or items covered by
the Division require authorization before the service may be provided. Services
requiring prior authorization are published on the Medicaid Behavioral Health Services
Fee Schedule.
(2) The Division shall authorize
payment for the type of service or level of care that meets the recipient’s
medical need and that has been adequately documented.
(3) The Division shall only
authorize services that are medically appropriate and for which the required documentation
has been supplied. The Division may request additional information from the provider
to determine medical appropriateness.
(4) Documentation submitted
when requesting authorization shall support the medical justification for the service.
The authorization request shall contain:
(a) A cover sheet detailing
relevant provider and recipient Medicaid numbers;
(b) Requested dates of service;
(c) HCPCS or CPT Procedure
code requested; and
(d) Amount of service or
units requested;
(e) A behavioral health assessment
and service plan meeting the requirements described in OAR 309-019-0135 through
309-019-0140; or
(f) Any additional supporting
clinical information supporting medical justification for the services requested;
(g) For substance use disorder
services, the Division uses the American Society of Addition Medicine (ASAM) Patient
Placement Criteria second edition-revised (PPC-2R) to determine the appropriate
level of SUD treatment of care. Providers shall use the ASAM;
(h) For Applied Behavioral
Analysis services, the Division requires submission of:
(A) An evaluation as described
in OAR 410-172-0770(1) from a physician or psychologist experienced in the diagnosis
and treatment of autism;
(B) An order for treatment
as described in OAR 410-172-0770(1)(e) from a physician or psychologist experienced
in the diagnosis and treatment of autism;
(C) A functional analysis
and a behavior treatment plan from a Board Certified Behavior Analyst or a Board
Certified Assistant Behavior Analyst certified by the Oregon Behavior Analysis Regulatory
Board;
(D) A copy of a Division-authorized
standard needs assessment supporting the level of service requested;
(i) Residential treatment
services for children may require a letter of approval by a designated quality improvement
organization (QIO) as defined in this rule;
(j) Some services require
additional approval or authorization by a physician, the Authority, or designee.
Services requiring additional approval are listed on the Behavioral Health Fee Schedule
or described in this rule.
(5) The Division may not
authorize services under the following circumstances:
(a) The request received
by the Division was not complete;
(b) The provider did not
hold the appropriate license, certificate, or credential at the time services were
requested;
(c) The recipient was not
eligible for Medicaid at the time services were requested;
(d) The provider cannot produce
appropriate documentation to support medical appropriateness, or the appropriate
documentation was not submitted to the Division;
(e) The services requested
are not in compliance with OAR 410-120-1260 through 410-120-1860;
(f) Authorization for payment
may be given for a past date of service if:
(A) On the date of service,
the recipient was made retroactively eligible or was retroactively dis-enrolled
from a Coordinated Care Organization (CCO) or Prepaid Health Plan (PHP);
(B) The services provided
meet all other criteria and Division or Authority administrative rules and;
(C) The request for authorization
is received within 30 days of the date of service.
(6) Any requests for authorization
after 30 days from date of service require documentation from the provider that
authorization could not have been obtained within 30 days of the date of service.
(7) Payment authorization
is valid for the time-period specified on the authorization notice but may not exceed
12 months unless the recipient’s benefit package no longer covers the service,
in which case the authorization shall terminate on the date coverage ends.
(8) Prior authorization of
services shall be subject to periodic utilization review and retrospective review
to ensure services meet the definition of medical appropriateness.
(9) Payments shall be made
for the provision of active treatment services. If active treatment is not documented
during any period in which the Division has prior authorized services, the Division
may limit or cancel prior authorization or recoup such payments.
(10) If providers fail to
comply with requests for documents for purposes of verifying medical appropriateness
within the specified time-frames, the Authority may deem the records non-existent
and cancel prior authorization.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
Service Specific Rules
410-172-0660
Rehabilitative Mental Health Services
(1) Rehabilitative mental health services
means medical or remedial services recommended by a licensed medical practitioner
or other licensed practitioner to reduce impairment to an individual’s functioning
associated with the symptoms of a mental disorder or substance use disorder and
are intended to restore functioning to the highest degree possible.
(2) Remedial rehabilitative
behavioral health services shall be recommended by a licensed practitioner of the
healing arts within the scope of their practice under state law.
(3) Rehabilitative behavioral
health services that include medical services shall be provided under ongoing oversight
of a licensed medical practitioner.
(4) Paid providers of rehabilitative
behavioral health services shall meet one of the following qualifications or hold
at least one of the following educational degrees and valid licensure:
(a) Physician or Physician
Assistant licensed by the Oregon Medical Board;
(b) Advanced Practice Nurse
including Clinical Nurse Specialist and Certified Nurse Practitioner licensed by
the Oregon Board of Nursing;
(c) Psychologist licensed
by the Oregon Board of Psychology;
(d) Professional Counselor
or Marriage and Family Therapist licensed by the Oregon Board of Licensed Professional
Counselors and Therapists;
(e) Clinical Social Worker
licensed by the Oregon Board of Licensed Social Workers;
(f) Certificate issued by
AMH as described in OAR 309-012-0130 through 309-012-0220.
(5) Non-paid providers shall
be employed by a provider organization certified by AMH as described in OAR 309-012-0130
through 309-012-0220 and meet one of the following qualifications:
(a) Qualified mental health
professional as defined in OAR 309-019-0105;
(b) Qualified mental health
associate as defined in OAR 309-019-0105;
(c) Mental health intern
as defined in OAR 309-019-0105; or
(d) Peer-Support Specialist
as defined in OAR 410-180-0305.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0670
Substance Use Disorder Treatment Services
(1) Substance Use Disorder (SUD) treatment
services include, but are not limited to, screening; assessment; individual counseling;
group counseling; individual family, group or couple counseling; care coordination;
medication-assisted treatment; medication management; collection and handling of
specimens for substance analysis; interpretation services; detoxification for substance
use disorders; synthetic opioid treatment; and acupuncture.
(2) Paid providers of SUD
treatment services shall meet one of the following requirements:
(a) Outpatient substance
use disorder providers shall have a certificate issued by AMH as described in OAR
chapter 415 division 012;
(b) Any facility that meets
the definition of a residential treatment facility for substance-dependent individuals
under ORS 443.400 or a detoxification center as defined in ORS 430.306 shall have
a certificate issued by AMH as described in OAR chapter 415, division 012;
(c) Synthetic opioid treatment
programs shall meet the requirements described in OAR chapter 415, division 020.
(d) Substance use detoxification
programs shall meet the standards described in OAR 415, chapter 050.
(e) Physician or Physician
Assistant licensed by the Oregon Medical Board;
(f) Advanced Practice Nurse
including Clinical Nurse Specialist and Certified Nurse Practitioner licensed by
the Oregon Board of Nursing;
(g) Professional Counselor
or Marriage and Family Therapist licensed by the Oregon Board of Licensed Professional
Counselors and Therapists;
(h) Clinical Social Worker
licensed by the Oregon Board of Licensed Social Workers;
(i) Psychologist licensed
by the Oregon Board of Psychology;
(j) Acupuncturist licensed
by the Oregon Medical Board;
(k) Non-paid providers shall
be employed by a provider organization licensed or certified by AMH and meet one
of the following qualifications for the scope of service provided:
(A) Qualified mental health
professional as defined in OAR 309-019-0105;
(B) Qualified mental health
associate as defined in OAR 309-019-0105;
(C) Mental health intern
as defined in OAR 309-019-0105;
(D) Peer-support specialist
as defined in OAR 410-180-0305;
(L) SUD counselor certified
by a national or state accrediting body, including Certified Alcohol and Drug Counselor
(CADC) certificate issued by the Addictions Counselor Certification Board of Oregon
(ACCBO) including:
(A) CADC I - Requires education,
supervised experience hours, and successful completion of a written examination:
150 hours of SUD education provided by an accredited or approved body; 1,000 hours
of supervised experience; completion of the NCAC I professional psychometric national
certification examination from the National Association of Alcohol and Drug Abuse
Counselors;
(B) CADC II – Requires
a minimum of a BA or BS degree with a minimum of 300 hours of SUD education provided
by an accredited or approved body; 4,000 hours of supervised experience; completion
of the NCAC II professional psychometric national certification examination from
the National Association of Alcohol and Drug Abuse Counselors;
(C) CADC III – Requires
a minimum of a Master’s degree with a minimum of 300 hours of SUD education
provided by an accredited or approved body; 6,000 hours of supervised experience;
completion of the NCAC II professional psychometric national certification examination
from the National Association of Alcohol and Drug Abuse Counselors.
(3) Treatment staff holding
certification in addiction counseling, qualification for the certification shall
include at least: 750 hours of supervised experience in substance use counseling;
150 contact hours of education and training in substance use related subjects; and
successful completion of a written objective examination or portfolio review by
the certifying body.
(4) For treatment staff holding
a health license described in this rule, the provider shall possess documentation
of at least 60 (120 for supervisors) contact hours of academic or continuing professional
education in SUD treatment.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0680
Residential Treatment Services for Children
(1) Paid providers of children’s
psychiatric residential treatment services shall:
(a) Hold a Certificate of
Approval Pursuant to OAR 309-012-0130 through 309-012-0220 from AMH; and
(b) Be accredited as a psychiatric
residential treatment facility for children under age 18 by JCAHO, CARF, or any
other accrediting organization with comparable standards that is recognized by the
State of Oregon;
(c) Be licensed by the Office
of Licensing and Regulatory Oversight (OLRO);
(2) Residential Treatment
Services for Children shall provide a program consistent with standards set by JCAHO,
CARF, or any other accrediting organization with comparable standards that is recognized
by the state.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0690
Admission Procedure for Residential Treatment
Services for Children
(1) Admission procedures for children
eligible for Medicaid shall be reviewed through an independent psychiatric review
process established by the Division to certify the need for services.
(2) The referring source
or the facility shall make available for the Certificate of Need (CONS) process
the following information about the referred child:
(a) A written psychological
or psychiatric evaluation completed within the previous 60 days;
(b) A written psychosocial
history following the format required by the admission procedure of the facility
to which the child has been referred;
(c) Results of any direct
recipient observation and assessment subsequent to the referral;
(d) Other information from
the referral source, other involved community agencies, and the family that are
pertinent and appropriate to the admission procedure;
(e) Level of Need Determination
Process outcome and Child and Adolescent Service intensity instrument (CASII) score;
(f) Identified care coordinator;
(g) Identified Intensive
Community Based Treatment Services (ICTS) provider;
(h) Identified child and
family team members;
(i) Service Coordination
Plan or expected date of completion;
(j) Documentation regarding
attempt or failure at lower level of care placement;
(k) Letter from Community
Mental Health Program (CMHP) approving the referral to this level of care;
(L) Documentation that private
insurance benefit will not fund stay.
(3) Certification for emergency
admissions shall be made by the team responsible for a plan of care as described
in CFR 441.156 within 14 days from the date of admission.
(4) The Division shall authorize
payment for psychiatric residential treatment services for children upon the approval
of a certificate of need by the Division or designee.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0700
1915(i) Home and Community Based Services
(1) Habilitation services are designed
to help an individual attain or maintain their maximal level of independence, including
the individual’s acceptance of a current residence and the prevention of unnecessary
changes in residence. Services are provided in order to assist an individual to
acquire, retain, or improve skills in one or more of the following areas: Assistance
with activities of daily living, cooking, home maintenance, community inclusion
and mobility, money management, shopping, community survival skills, communication,
self-help, socialization, and adaptive skills necessary to reside successfully in
home and community-based settings.
(2) Psychosocial rehabilitation
services are medical or remedial services recommended by a licensed physician or
other licensed practitioner to reduce impairment to an individual’s functioning
associated with the symptoms of a mental disorder or to restore functioning to the
highest degree possible.
(3) Paid providers of 1915(i)
services shall meet one of the following qualifications:
(a) Physician or Physician
Assistant licensed by the Oregon Medical Board;
(b) Advanced Practice Nurse
including Clinical Nurse Specialist and Certified Nurse Practitioner licensed by
the Oregon Board of Nursing;
(c) Professional Counselor
or Marriage and Family Therapist licensed by the Oregon Board of Licensed Professional
Counselors and Therapists;
(d) Clinical Social Worker
licensed by the Oregon Board of Licensed Social Workers;
(e) Psychologist licensed
by the Oregon Board of Psychology;
(f) Residential treatment
home or facility licensed pursuant to OAR chapter 309, division 035;
(g) Adult Foster Home licensed
pursuant to OAR chapter 309, division 040;
(h) Certificate issued by
AMH pursuant to OAR chapter 309, division 012;
(4) Non-paid providers shall
be employed or subcontracted with a provider licensed or certified by AMH and meet
one of the following qualifications:
(a) Qualified Mental Health
Professional as defined in OAR 309-019-0105;
(b) Qualified Mental Health
Associate as defined in OAR 309-019-0105;
(c) Mental Health Intern
as defined in OAR 309-019-0105;
(d) Peer-Support Specialist
as defined in OAR 410-180-0305;
(e) Recovery Assistant.
(5) Providers of 1915(i)
services may be required to meet Community Mental Health Program (CMHP) liability
insurance requirements.
(6) Due to federal requirements
for the Authority to ensure the impartiality of paid providers rendering services
to 1915(i) eligible members, providers may be restricted from conducting eligibility
reviews or developing the behavioral health assessment or service plan.
(7) To be eligible for services
under the 1915(i) State Plan HCBS, the individual shall meet the following requirements:
(a) Been diagnosed with a
chronic mental illness as defined in ORS 426.495;
(b) Been assessed as needing
assistance to perform at least two personal care services as identified in these
rules due to a chronic mental illness.
(8) Eligibility for 1915(i)
services is determined by an external Quality Improvement Organization (QIO) as
identified by the Division.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0710
Residential Personal Care
(1) Personal care services provided
to a resident of an AMH licensed residential treatment program include a range of
assistance, as developmentally appropriate, and are provided to individuals with
behavioral health conditions that enable them to accomplish tasks that they would
normally do for themselves if they did not have a behavioral health condition. Assistance
may be in the form of hands-on assistance (actually performing a personal care task)
or cueing (redirecting) so that the individual performs the task by him or herself.
(2) Personal care assistance
most often relates to performance of activities of daily living (ADLs) and instrumental
activities of daily living (IADLs). ADLs include eating, bathing, dressing, toileting,
transferring, and maintaining continence. IADLs capture more complex life activities
and include personal hygiene, light housework, laundry, meal preparation, transportation,
grocery shopping, using the telephone, medication management, and money management.
(3) Personal care services
may be provided on a continuing basis or on episodic occasions.
(4) Paid providers of facility-based
personal care services shall meet one of the following:
(a) Licensed residential
facility pursuant to OAR chapter 309, divisions 035 and 040;
(b) Secure Residential Treatment
Facility (SRTF);
(c) Residential Treatment
Facility (RTF);
(d) Residential Treatment
Home (RTH);
(e) Adult Foster Home (AFH).
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0720
Prior Authorization and Re-Authorization
for Residential Treatment
(1) The Authority does not consider
a request for a fixed episode of care or standardized length of stay to be medically
appropriate. Requested length of stay shall be based on an assessment of individual
need and the medical appropriateness of the proposed time for treatment.
(2) Residential treatment
is intended as an outcome-based, transitional, and episodic period of care to provide
service and supports in a structured environment that will allow the individual
to successfully reintegrate into an independent community-based living arrangement.
(3) Residential treatment
is not intended to be used as a long-term substitute for lack of available supportive
living environment in the community.
(4) Authority licensed residential
treatment programs are reimbursed for the provision of rehabilitation, substance
use disorder, habilitation, or personal care services as defined in these rules.
(5) The Division shall authorize
admission and continued stay in residential programs based on the medical appropriateness
of the request and supporting clinical documentation.
(6) Prior authorization requests
for admission and continued stay may be reviewed to determine:
(a) The medical appropriateness
of the admission for residential services provided;
(b) The appropriateness of
the recommended length of stay;
(c) The appropriateness of
the recommended plan of care;
(d) The appropriateness of
the licensed setting selected for service delivery;
(e) A level of care determination
was appropriately documented.
(7) If the Division determines
that a residential service prior authorization request is not within coverage parameters,
the provider shall be notified in writing and shall have ten business days to provide
additional written documentation to support the medical appropriateness of the admission
and procedures.
(8) If the reconsidered decision
is to uphold the denial, prior authorization shall be denied.
(9) The provider may appeal
any final decision through the Division administrative appeals process as described
in OAR 410 120-1560 through1875.
(10) Upon denial of a prior
authorization request for continued stay, the Division shall authorize payment for
up to 60 days of continued stay for the purposes of supporting transition management
and planning for the recipient.
(11) The Division shall determine
re-authorization and authorization of continued stays based upon one of the following:
(a) The recipient continues
to meet all basic elements of medical appropriateness and;
(b) One of the following
criteria shall be met:
(A) Documentation that the
treatment provided is resulting in measurable clinical outcomes but that the recipient
is not sufficiently stabilized or yet developed the skills necessary to support
transition to a less restrictive level of care;
(B) The recipient has developed
new or worsening symptoms or behaviors that require continued stay in the current
level of care;
(12) Requests for continued
stay based on these criteria shall include documentation of ongoing re-assessment
and necessary modification to the current treatment plan or residential plan of
care.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0730
Payment Limitations for Behavioral Health
Services
(1) Services shall be subject to periodic
utilization review to determine medical appropriateness.
(2) If a review reveals that
a recipient received less than active treatment, payment shall not be allowed under
these rules and prior authorization may be cancelled.
(3) The Division shall make
no payment for services if the Division or designee has determined the service is
not medically appropriate.
(4) Residential treatment
services are provided to Medicaid Title XIX eligible individuals in facilities with
16 or fewer beds. Payment is excluded for individuals in “institutions of
mental diseases” (IMD) who are over age 18 and under age 65. IMDs are defined
in 42 CFR 435.1010.
(5) For residential facilities,
the Division may not pay for planned or unplanned absences unless the provider can
document clinical services were rendered during the temporary absence.
(6) For residential facilities,
the Division shall pay for the day of admission but may not pay for the day of transfer
or discharge.
(7) Medicaid may not reimburse
costs associated with room and board for recipients residing in Authority licensed
residential treatment programs.
(8) Consistent with 42 CFR
447.40, payment for a reserved bed is not covered under Medicaid.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0740
Supported Employment
(1) To be eligible for Medicaid reimbursement,
supported employment (SE) services shall be provided by a qualified SE provider.
(2) To become a qualified
SE provider, an agency shall provide the evidence-based practice of individual placement
support (IPS) and SE and submit a copy to AMH of a fidelity review conducted by
an AMH approved fidelity reviewer that resulted in a score of 100 or better.
(3) Providers implementing
IPS supported employment may become a provisionally-qualified SE provider by submitting
a request to AMH with a letter of support that indicates receipt of technical assistance
and training from an AMH approved IPS SE trainer. Medicaid reimbursement to a provisionally-qualified
SE provider ends after 12 months. This option is intended only for providers initiating
SE services.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0750
Assertive Community Treatment (ACT)
(1) Assertive Community Treatment (ACT)
services shall be provided by a qualified ACT provider to be eligible for Medicaid
reimbursement.
(2) An agency shall provide
the evidence-based practice of ACT to become a qualified ACT provider and submit
to AMH a copy of a fidelity review conducted by an AMH approved ACT Fidelity Reviewer
with a minimum score of 114.
(3) Agencies may become a
provisionally-qualified ACT provider by submitting to AMH a request with a letter
of support that indicates receipt of technical assistance and training from an AMH
approved ACT Trainer. Provisional ability to receive Medicaid reimbursement shall
end after 12 months. This option is intended only for providers initiating ACT services.
(4) If a Qualified ACT provider
does not receive a minimum score of 114 on a fidelity review, the following shall
occur:
(a) Technical assistance
shall be made available for a period of 90 days to address problem areas identified
in the fidelity review;
(b) At the end of the 90-day
period, a follow-up review shall be conducted by an AMH approved reviewer.
(5) The provider shall forward
a copy of the amended fidelity review report to AMH.
(6) If the 90-day review
results in a score of less than 114, the agency’s designation as a Qualified
ACT provider may be suspended for up to one calendar year.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0760
Applied Behavior Analysis
(1) ABA services shall be recommended
by a licensed physician or licensed psychologist who has experience or training
in the diagnosis of autism spectrum disorder and holds at least one of the following
educational degrees and valid licensure:
(a) Physician licensed to
practice in the State of Oregon;
(b) Psychologist licensed
to practice in the State of Oregon;
(2) Paid providers of ABA
services shall hold the following license or registration:
(a) Licensed Behavior Analyst
as described in OAR 824-030-0010;
(b) Licensed health care
professional who is registered with the Oregon Behavior Analyst Certification Board
as described in OAR 824-030-0030.
(3) Non-paid providers of
ABA services shall hold the following license or registration:
(a) Assistant Behavior Analyst
licensed by the Oregon Behavior Analysis Regulatory Board as described in OAR 824-030-0020;
(b) Behavior Analysis Interventionists
registered by the Oregon Behavior Analysis Regulatory Board as described in OAR
824-030-0040.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0770
Individual Eligibility for Applied Behavioral
Analysis Treatment
(1) Prior to receiving services, individuals
receiving ABA shall have an evaluation by a physician or psychologist experienced
in the diagnosis and treatment of autism using the current DSM criteria that includes:
(a) A Diagnosis of an Autism
spectrum disorder;
(b) Documentation of and
results from a standardized tool that has been used to substantiate the autism disorder
or questionnaires that have been used to substantiate a diagnosis of self-injurious
behavior;
(c) Documentation of behaviors
that are considered to have an adverse impact on the individual’s development
or communication;
(d) Documentation of behavior
that is injurious to themselves or others and that interferes with everyday functions
or activities;
(e) Documentation that less
intensive treatment or other therapy has been considered or found insufficient;
(f) Any other documentation
that would substantiate the diagnosis of autism or self-injurious behavior such
as:
(A) Notes from well-child
visits or other medical professionals;
(B) Copy of existing or past
Individual Education Plans (IEP);
(C) Results from any additional
assessments such as IQ tests, speech and language tests, or tests of auditory function.
(g) A prescription for ABA
treatment shall include:
(A) A diagnosis of autism
or self-injurious behavior;
(B) A copy of the evaluation
described above;
(C) An order for ABA treatment
without specifying hours or intensity.
(2) Recipients ages one through
twelve are eligible for intensive and less intensive interventions:
(a) Intensive interventions
include therapies that address multiple behaviors at once, are more comprehensive
in nature, and start at an earlier age;
(b) Less intensive interventions
focus on a few targeted behaviors and generally are used with older children.
(3) Recipients age 13 and
older are eligible for less intensive services only.
(4) Intensive and less intensive
interventions are based on medical appropriateness as defined in these rules.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0780
Behavioral Health Personal Care Attendant
Program
(1) Behavioral health personal care
attendant services are essential services that enable an individual to move into
or remain in his or her own home. Behavioral health personal care attendant services
are provided in accordance with an individual’s authorized plan for services
by a QMHA or QMHP as defined in OAR 309-019-0105:
(a) Behavioral health personal
care attendant services are provided directly to an eligible individual and are
not meant to provide respite or other services to an individual’s natural
support system. Behavioral health personal care attendant services may not be implemented
for the purpose of benefiting an individual’s family members or the individual’s
household in general;
(b) Behavioral health personal
care attendant services are limited to 20 hours per month per eligible individual;
(c) To meet an extraordinary
personal care need, an individual, representative, or legal representative may request
an exception to the 20-hour per month limitation. An exception shall be requested
through the local community mental health program or agency contracted with the
Authority serving the individual. The Division has up to 45 days upon receipt of
an exception request to determine whether an individual’s assessed personal
care needs warrant exceeding the 20-hour per month limitation.
(2) Personal care services
include:
(a) Basic personal hygiene,
providing or assisting an individual with such needs as bathing (tub, bed bath,
shower), washing hair, grooming, shaving, nail care, foot care, dressing, skin care,
mouth care, and oral hygiene;
(b) Toileting, bowel, or
bladder care, assisting to and from bathroom, on and off toilet, commode, bedpan,
urinal, or other assistive device used for toileting, changing incontinence supplies,
following a toileting schedule, cleansing an individual or adjusting clothing related
to toileting, emptying a catheter drainage bag or assistive device, ostomy care,
and bowel care;
(c) Mobility, transfers,
or repositioning, assisting an individual with ambulation or transfers with or without
assistive devices, turning an individual or adjusting padding for physical comfort
or pressure relief, and encouraging or assisting with range-of-motion exercises;
(d) Nutrition, preparing
meals and special diets, assisting with adequate fluid intake or adequate nutrition,
assisting with food intake (feeding), monitoring to prevent choking or aspiration,
assisting with special utensils, cutting food, and placing food, dishes, and utensils
within reach for eating;
(e) Medication or oxygen
management, assisting with ordering, organizing, and administering oxygen or prescribed
medications (including pills, drops, ointments, creams, injections, inhalers, and
suppositories), monitoring for choking while taking medications, assisting with
the administration of oxygen, maintaining clean oxygen equipment, and monitoring
for adequate oxygen supply;
(f) Delegated nursing tasks,
as defined in OAR 411-034-0010.
(3) When any of the services
listed in section (2) of this rule are essential to the health, safety, and welfare
of an individual and the individual is receiving personal care paid by the Division,
the following support services may also be provided:
(a) Housekeeping tasks necessary
to maintain the individual in a healthy and safe environment, including cleaning
surfaces and floors, making the individual’s bed, cleaning dishes, taking
out the garbage, dusting, and gathering and washing soiled clothing and linens.
Only the housekeeping activities related to the individual’s needs may be
considered in housekeeping;
(b) Arranging for necessary
medical appointments including help scheduling appointments and arranging medical
transportation services (described in OAR chapter 410, division 136) and assistance
with mobility and transfers or cognition in getting to and from appointments or
to an office within a medical clinic or center;
(c) Observing the individual’s
health status and reporting any significant changes to physicians, health care professionals,
or other appropriate persons;
(d) First aid and handling
of emergencies, including responding to medical incidents related to conditions
such as seizures, spasms, or uncontrollable movements where assistance is needed
by another individual and responding to an individual’s call for help during
an emergent situation or for unscheduled needs requiring immediate response; and
(e) Cognitive assistance
or emotional support provided to an individual by another person due to confusion,
dementia, behavioral symptoms, or mental or emotional disorders. Cognitive assistance
or emotional support includes helping the individual cope with change and assisting
the individual with decision-making, reassurance, orientation, memory, or other
cognitive symptoms.
(4) Payment may not be made
for any of the following excluded services:
(a) Shopping;
(b) Community transportation;
(c) Money management;
(d) Mileage reimbursement;
(e) Social companionship;
(f) Day care, adult day services
(described in OAR chapter 411, division 066), respite, or baby-sitting services;
(g) Medicaid home delivered
meals (described in OAR chapter 411, division 040);
(h) Care, grooming, or feeding
of pets or other animals; or
(i) Yard work, gardening,
or home repair.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0790
Eligibility for Behavioral Health Personal
Care Attendant Services
(1) To be eligible for Behavioral Health
personal care attendant services, an individual shall:
(a) Demonstrate the need
for assistance from a qualified provider due to a disabling behavioral health condition
with personal care services and meet the eligibility criteria described in this
rule;
(b) Be a current recipient
of a Medicaid OHP full benefit package.
(2) An individual is not
eligible to receive Behavioral Health personal care attendant services if:
(a) The individual is receiving
personal care services from a licensed 24-hour residential services program (such
as an adult foster home, residential treatment home, or residential treatment facility);
(b) The individual is in
a prison, hospital, sub-acute care facility, nursing facility, or other medical
institution;
(c) The individual’s
assessed service needs are being met under other Medicaid-funded home and community-based
service options of the individual’s choosing.
(3) Behavioral health personal
care attendant services are not intended to replace routine care commonly needed
by an infant or child typically provided by the infant’s or child’s
parent.
(4) Behavioral health personal
care attendant services may not be used to replace other non-Medicaid governmental
services.
(5) The Authority may close
the eligibility and authorization for Behavioral Health personal care attendant
services if an individual fails to:
(a) Employ a provider that
meets the requirements in this rule;
(b) Receive personal care
from a qualified provider paid by the Authority for 30 continuous calendar days
or longer.
(6) Behavioral health personal
care attendant services may not duplicate other Medicaid services.
(7) Individuals eligible
for Behavioral Health personal care attendant services as described shall apply
through the local community mental health program or agency contracted with AMH.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0800
Personal Care Attendant Employer-Employee
Relationship
(1) The relationship between a provider
and an eligible individual or the individual’s representative is that of employee
and employer.
(2) As an employer, the individual
shall create and maintain a job description for a potential provider that is in
coordination with the individual’s plan for services.
(3) The only benefits available
to homecare and personal support attendants are those negotiated in a collective
bargaining agreement and as provided in statute. The collective bargaining agreement
does not include participation in the Public Employees Retirement System or the
Oregon Public Service Retirement Plan. Homecare and personal support workers are
not state or Division employees.
(4) To be eligible for Behavioral
Health personal care attendant services, the individual or the individual’s
representative shall demonstrate the ability to:
(a) Locate, screen, and hire
a provider meeting the requirements described in this rule;
(b) Supervise and train a
provider;
(c) Schedule work, leave,
and coverage;
(d) Track the hours worked
and verify the authorized hours completed by a provider;
(e) Recognize, discuss, and
attempt to correct any performance deficiencies with the provider and provide appropriate,
progressive, disciplinary action as needed; and
(f) Discharge an unsatisfactory
provider.
(5) The Authority shall pay
for Behavioral Health personal care attendant services to the provider on an individual’s
behalf. Payment for services is not guaranteed until the Authority has verified
that an individual’s provider meets the qualifications set forth in this rule.
(6) In order to receive Behavioral
Health personal care attendant services from a personal support worker or homecare
worker, an individual shall be able to meet or designate a representative to meet
the employer responsibilities in section (4) of this rule.
(7) Termination and the grounds
for termination of employment are determined by an individual or the individual’s
representative. An individual may terminate an employment relationship with a provider
at any time and for any reason. An individual shall establish an employment agreement
at the time of hire. The employment agreement may include grounds for dismissal,
notice of resignation, work scheduling, and absence reporting.
(8) After appropriate intervention,
an individual unable to meet the employer responsibilities in section (4) of this
rule may be determined ineligible for Behavioral Health personal care attendant
services.
(9) An individual determined
ineligible for Behavioral Health personal care attendant services may request these
services at the individual’s next annual re-assessment. Improvements in health
and cognitive functioning may be factors in demonstrating the individual’s
ability to meet the employer responsibilities described in section (4) of this rule.
The waiting period may be shortened if an individual is able to demonstrate the
ability to meet the employer responsibilities sooner than the individual’s
next annual re-assessment.
(10) An individual may designate
a representative to act on the individual’s behalf to meet the employer responsibilities
in section (4) of this rule. An individual’s legal representative may be designated
as the individual’s representative:
(a) The Authority may deny
an individual’s designation of a representative if the representative has:
(A) A history of a substantiated
abuse of an adult as described in OAR chapter 411, division 20, OAR chapter 407,
division 45, or OAR chapter 943, division 45;
(B) A history of founded
abuse of a child as described in ORS 419 B.005;
(C) Participated in billing
excessive or fraudulent charges; or
(D) Failed to meet the employer
responsibilities, including previous termination for failure to meet the employer
responsibilities in section (4) of this rule.
(b) An individual may select
another representative if the Authority suspends, terminates, or denies an individual’s
designation of a representative.
(11) An individual with a
guardian shall have a representative for service planning purposes. A guardian may
designate themselves the individual’s representative.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0810
Personal Care Attendant Qualifications
(1) A qualified provider is an individual
who, in the Authority’s judgment, demonstrates by background, skills, and
abilities knowledge and ability to perform or to learn to perform the required work.
A qualified provider shall:
(a) Maintain a drug-free
work place;
(b) Complete the background
check process described in OAR 943, division 007 with an outcome of approved or
approved with restrictions;
(c) May not be an individual’s
legal representative;
(d) Be authorized to work
in the United States in accordance with U.S. Department of Homeland Security, Bureau
of Citizenship and Immigration rules;
(e) Be 18 years of age or
older.
(2) A qualified provider
may be employed through a contracted in-home care agency or enrolled as a homecare
worker or personal support worker under a provider number. The Authority shall establish
the rates for services.
(3) Providers that provide
Behavioral Health personal care attendant services shall:
(a) Be enrolled in the Consumer-Employed
Provider Program and meet all of the standards in OAR chapter 411, division 31;
(b) Meet the provider enrollment
and termination criteria described in OAR 411-031-0040 for personal support workers.
(4) The Authority shall conduct
background rechecks at least every other year from the date a provider is enrolled.
The Authority may conduct a recheck more frequently based on additional information
discovered about a provider, such as possible criminal activity or other allegations.
(5) Prior background check
approval for another Authority provider type is inadequate to meet background check
requirements for homecare or personal support workers.
(6) Provider enrollment may
be inactivated when a provider fails to comply with the background recheck process.
Once a provider’s enrollment is inactivated, the provider shall reapply and
meet the requirements described in these rules to reactivate provider enrollment.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0820
Provider Termination
(1) The Authority may deny or terminate
a personal care attendant’s provider enrollment and provider number as described
in OAR 411-031-0050. The termination, administrative review, and hearings rights
for homecare workers are set forth in OAR 411-031-0050.
(2) The Authority may deny
or terminate a personal support worker’s provider enrollment and provider
number when the personal support worker:
(a) Has been appointed the
legal guardian of an individual;
(b) Has a background check
that results in a closed case pursuant to OAR chapter 943, division 007;
(c) Lacks the skills, knowledge,
or ability to perform or learn to perform the required work;
(d) Violates the protective
service and abuse rules in OAR chapter 411, division 20, OAR chapter 407, division
45, and OAR chapter 943, division 45;
(e) Commits fiscal improprieties;
(f) Fails to provide the
authorized services required by an eligible individual;
(g) Has been repeatedly late
in arriving to work or has absences from work not authorized in advance by an individual;
(h) Has been intoxicated
by alcohol or drugs while providing authorized services to an individual or while
in the individual’s home;
(i) Has manufactured or distributed
drugs while providing authorized services to an individual or while in the individual’s
home; or
(j) Has been excluded as
a provider by the U.S. Department of Health and Human Services, Office of Inspector
General from participation in Medicaid, Medicare, or any other federal health care
programs.
(3) A personal support worker
may contest the Authority’s decision to terminate the personal support worker’s
provider enrollment and provider number:
(a) A designated employee
from the Authority shall review the termination and notify the personal support
worker of the decision;
(b) A personal support worker
may file a request for a hearing with the Authority’s local office if all
levels of administrative review have been exhausted and the provider continues to
dispute the Authority’s decision. The local office shall file the request
for a hearing with the Office of Administrative Hearings as described in OAR chapter
137, division 3. The request for a hearing shall be filed within 30 calendar days
of the date of the written notice from the Authority;
(c) When a contested case
is referred to the Office of Administrative Hearings, the referral shall indicate
whether the Authority is authorizing a proposed order, a proposed and final order,
or a final order;
(d) No additional hearing
rights have been granted to a personal support worker by this rule other than the
right to a hearing on the Authority’s decision to terminate provider enrollment.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0830
Personal Care Attendant Service Assessment,
Authorization, and Monitoring
(1) A behavioral health case manager
shall meet in person with an individual to assess the individual’s ability
to perform the personal care tasks listed in this rule:
(a) An individual’s
natural supports may participate in the assessment if requested by the individual;
(b) A behavioral health case
manager shall assess an individual’s service needs, identify the resources
meeting any, some, or all of the individual’s needs and determine if the individual
is eligible for behavioral health personal care attendant services or other services;
(c) A behavioral health case
manager shall meet with an individual in person at least once every 365 days to
review the individual’s service needs.
(2) A behavioral health case
manager shall prepare a service plan identifying the tasks for which an individual
requires assistance and the number of monthly authorized service hours. The case
manager shall document an individual’s natural supports that currently meet
some or all of the individual’s assistance needs:
(a) The service plan shall
describe the tasks to be performed by a qualified provider and shall authorize the
maximum monthly hours that may be reimbursed for those services;
(b) A case manager shall
consider the cost effectiveness of services that adequately meet the individual’s
service needs when developing service plans;
(c) Payment for behavioral
health personal care attendant services shall be prior authorized by a behavioral
health case manager and based on the service needs of an individual as documented
in the individual’s written service plan.
(3) When there is an indication
that an individual’s personal care needs have changed, a case manager shall
conduct an in-person reassessment with the individual and any of the individual’s
natural supports if requested by the individual:
(a) Following annual reassessments
and those conducted after a change in an individual’s personal care needs,
a case manager shall review service eligibility, the cost effectiveness of the individual’s
service plan, and whether the services provided are meeting the individual’s
identified service needs;
(b) The case manager may
adjust the hours or services in the individual’s service plan and shall authorize
a new service plan, if appropriate, based on the individual’s current service
needs.
(4) A behavioral health case
manager shall provide ongoing coordination of behavioral health personal care attendant
services, including authorizing changes in providers and service hours, addressing
risks, and monitoring and providing information and referral to an individual when
indicated.
(5) The Authority may not
authorize services within an eligible individual’s home when:
(a) The individual’s
home has dangerous conditions that jeopardize the health or safety of the individual
or the provider and necessary safeguards cannot be taken to improve the setting;
(b) The services cannot be
provided safely or adequately by a provider;
(c) The individual does not
have the ability to make an informed decision, does not have a designated representative
to make decisions on his or her behalf, and necessary safeguards cannot be provided
to protect the individual’s safety, health, and welfare.
(6) A behavioral health case
manager shall present an individual or the individual’s representative with
information on service alternatives and provide assistance to assess other choices
when a provider or service setting selected by the individual or the individual’s
representative is not authorized.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0840
Personal Care Attendant Payment Limitations
(1) The number of behavioral health
personal care attendant service hours authorized for an individual per calendar
month is based on projected amounts of time to perform specific personal care and
supportive services to the eligible individual. The total of these hours are limited
to 20 hours per individual per month. Individuals whose assessed service needs exceed
the 20 hour limit may receive approval for additional hours.
(2) The Authority shall pay
for behavioral health personal care attendant services when all acceptable provider
enrollment standards have been verified and both the employer and provider have
been formally notified in writing that payment by the Authority is authorized.
(3) In accordance with OAR
410-120-1300, all provider claims for payment shall be submitted within 12 months
of the date of service.
(4) Payment may not be claimed
by a provider until the hours authorized for the payment period have been completed,
as directed by an eligible individual or the individual’s representative.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0850
Telemedicine for Behavioral Health
(1) Telemedicine encompasses different
types of programs, services, and delivery mechanisms for medically appropriate covered
services within the recipient’s benefit package:
(a) Patient consultations
using telephone and online or electronic mail (e-mail) are covered when billed services
comply with the practice guidelines set forth by the Health Evidence Review Commission
and the applicable HERC-approved code requirements, delivered consistent with the
HERC Evidence-Based Guidelines;
(b) Patient consultations
using videoconferencing, a synchronous (live two-way interactive) video transmission
resulting in real time communication between a provider located in a distant site
and the recipient being evaluated and located in an originating site, is covered
when billed services comply with the billing requirements stated below.
(2) Behavioral health services
specifically identified as allowable for telephonic delivery are listed on the Behavioral
Health Fee schedule published by the Authority.
(3) Unless expressly authorized
in OAR 410-120-1200 (Exclusions), other types of telecommunications are not covered
such as images transmitted via facsimile machines and electronic mail when:
(a) Those methods are not
being used in lieu of videoconferencing, due to limited videoconferencing equipment
access; or
(b) Those methods and specific
services are not specifically allowed pursuant to the Oregon Health Evidence Review
Commission’s Prioritized List of Health Services and Evidence Based Guidelines.
(4) Providers billing for
covered telemedicine services shall:
(a) Comply with HIPAA and
the Authority’s Confidentiality and Privacy Rules and security protections
for the patient in connection with the telemedicine communication and related records;
(b) Obtain and maintain technology
used in the telemedicine communication that is compliant with privacy and security
standards in HIPAA and the Authority’s Privacy and Confidentiality Rules set
forth in OAR 943 division 14;
(c) Ensure policies and procedures
are in place to prevent a breach in privacy or exposure of patient health information
or records (whether oral or recorded in any form or medium) to unauthorized individuals;
(d) Comply with the relevant
HERC evidence-based guidelines for telephone and e-mail consultation. Refer to the
current prioritized list and evidence based guidelines at http://www.oregon.gov/oha/herc/Pages/PrioritizedList.aspx;
(e) Maintain clinical and
financial documentation related to telemedicine services as required in OAR 410-120-1360.
(5) For purposes of behavioral
health services, the Authority shall provide coverage for telemedicine services
to the same extent that the services would be covered if they were provided in person.
Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705 & 430.715
Hist.: DMAP 85-2014(Temp),
f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef.
6-26-15
410-172-0860
Billing for Dual Eligible Individuals
(1) As described in OAR 410-120-1280
(8), when an individual has both Medicare and coverage through Medicaid, providers
shall make reasonable efforts to obtain payment from other resources including Medicare
or other Third Party Liability (TPL).
(2) In accordance with OAR
410-120-1280 (f), OAR 410-141-0420, and OAR 410-141-3420, behavioral health providers
may bill the Division directly and may not be required to bill Medicare under the
following circumstances:
(a) For behavioral health
services that are never covered by Medicare or another insurer;
(b) For behavioral health
services that are not covered when rendered by the following provider types:
(A) Qualified Mental Health
Professional (non-licensed) as defined in OAR 309-019-0105;
(B) Qualified Mental Health
Associate as defined in OAR 309-019-0105;
(C) Professional Counselor
or Marriage and Family Therapist licensed by the Oregon Board of Licensed Professional
Counselors and Therapists;
(D) Certified Peer Support
Specialist as defined in OAR 410-180-0305;
(E) Recovery Assistant;
(F) Certified Alcohol and
Drug Counselor.
Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042,
414.025, 414.065, 430.640, 430.705, 430.715
Hist.: DMAP 32-2015, f. 6-24-15,
cert. ef. 6-26-15

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