In-Home Services

Link to law: http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_411/411_030.html
Published: 2015

The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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DEPARTMENT OF HUMAN SERVICES,

AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES




 

DIVISION 30
IN-HOME SERVICES

411-030-0002
Purpose
(1) The rules in OAR chapter 411, division
030 ensure that in-home services maximize independence, empowerment, dignity, and
human potential through the provision of flexible, efficient, and suitable services.
In-home services fill the role of complementing and supplementing an individual's
own personal abilities to continue to live in his or her own home or the home of
a relative.
(2) Medicaid in-home services
are provided through the Consumer-Employed Provider Program, Spousal Pay Program,
Independent Choices Program, and other approved service providers.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SSD 4-1993, f. 4-30-93,
cert. ef. 6-1-93; SPD 15-2004, f. 5-28-04, cert. ef. 6-7-04; SPD 15-2008, f. 12-26-08,
cert. ef. 1-1-09; SPD 10-2013(Temp), f. & cert. ef. 5-23-13 thru 11-19-13; SPD
43-2013, f. 10-31-13, cert. ef. 11-1-13
411-030-0020
Definitions
All temporary rule changes filed in
chapter 411, division 030 on September, 21, 2015 are effective as of August 31,
2015. Unless the context indicates otherwise, the following definitions apply to
the rules in OAR chapter 411, division 030:
(1) "AAA" means "Area Agency
on Aging" as defined in this rule.
(2) "Activities of Daily
Living (ADL)" mean those personal, functional activities required by an individual
for continued well-being, which are essential for health and safety. Activities
include eating, dressing, grooming, bathing, personal hygiene, mobility (ambulation
and transfer), elimination (toileting, bowel, and bladder management), and cognition,
and behavior as defined in OAR 411-015-0006.
(3) "ADL" means "activities
of daily living" as defined in this rule.
(4) "Architectural Modifications"
means any service leading to the alteration of the structure of a dwelling to meet
a specific service need of an eligible individual.
(5) "Area Agency on Aging
(AAA)" means the Department designated agency charged with the responsibility to
provide a comprehensive and coordinated system of services to individuals in a planning
and service area. The term Area Agency on Aging is inclusive of both Type A and
Type B Area Agencies on Aging as defined in ORS 410.040 and described in 410.210
to 410.300.
(6) "Assessment" or "Reassessment"
means an assessment as defined in OAR 411-015-0008.
(7) "Assistive Devices" means
any category of durable medical equipment, mechanical apparatus, electrical appliance,
or instrument of technology used to assist and enhance an individual's independence
in performing any activity of daily living. Assistive devices include the use of
service animals, general household items, or furniture to assist the individual.
(8) "Business Days" means
Monday through Friday and excludes Saturdays, Sundays, and state or federal holidays.
(9) "CA/PS" means the "Client
Assessment and Planning System" as defined in this rule.
(10) "Case Manager" means
an employee of the Department or Area Agency on Aging who assesses the service needs
of an individual applying for services, determines eligibility, and offers service
choices to the eligible individual. The case manager authorizes and implements an
individual's service plan and monitors the services delivered as described in OAR
chapter 411, division 028.
(11) "Client Assessment and
Planning System (CA/PS)":
(a) Is a single entry data
system used for:
(A) Completing a comprehensive
and holistic assessment;
(B) Surveying an individual's
physical, mental, and social functioning; and
(C) Identifying risk factors,
individual choices and preferences, and the status of service needs.
(b) The CA/PS documents the
level of need and calculates an individual's service priority level in accordance
with the rules in OAR chapter 411, division 15, calculates the service payment rates,
and accommodates individual participation in service planning.
(12) "Consumer" or "Consumer-Employer"
means an individual eligible for in-home services.
(13) "Consumer-Employed Provider
Program" refers to the program described in OAR chapter 411, division 31 wherein
a provider is directly employed by a consumer to provide either hourly or live-in
in-home services.
(14) "Contingency Fund" means
a monetary amount that continues month to month, if approved by a case manager,
that is set aside in the Independent Choices Program service budget to purchase
identified items that substitute for personal assistance.
(15) "Contracted In-Home
Care Agency" means an incorporated entity or equivalent, licensed in accordance
with OAR chapter 333, division 536 that provides hourly contracted in-home services
to individuals receiving services through the Department or Area Agency on Aging.
(16) "Cost Effective" means
being responsible and accountable with Department resources. This is accomplished
by offering less costly alternatives when providing choices that adequately meet
an individual’s service needs. Those choices consist of all available services
under the Medicaid home and community-based service options, the utilization of
assistive devices, natural supports, architectural modifications, and alternative
service resources (defined in OAR 411-015-0005). Less costly alternatives may include
resources not paid for by the Department.
(17) "Debilitating Medical
Condition" means the individual’s condition is severe and persistent and interferes
with the individual's ability to function and participate in most activities of
daily living.
(18) "Department" means the
Department of Human Services (DHS).
(19) "Discretionary Fund"
means a monetary amount set aside in the Independent Choices Program service budget
to purchase items not otherwise delineated in the monthly service budget or agreed
to be savings for items not traditionally covered under Medicaid home and community-based
services. Discretionary funds are expended as described in OAR 411-030-0100.
(20) "Disenrollment" means
either voluntary or involuntary termination of a participant from the Independent
Choices Program.
(21) "DMAP" means the Oregon
Health Authority, Division of Medical Assistance Programs.
(22) "Employee Provider"
means a worker who provides services to, and is a paid provider for, a participant
in the Independent Choices Program.
(23) "Employment Relationship"
means the relationship of employee and employer involving an employee provider and
a participant.
(24) "Exception" means the
following:
(a) An approval for payment
of a service plan granted to a specific individual in their current residence or
in the proposed residence identified in the exception request that exceeds the CA/PS
assessed service payment levels for individuals residing in community-based care
facilities or the maximum hours of service as described in OAR 411-030-0070 for
individuals residing in their own homes or the home of a relative.
(b) An approval for a live-in
or shift care service plan granted to a specific individual that does not otherwise
meet the criteria as described in OAR 411-030-0068 based upon the service needs
of the individual as determined by the Department.
(c) An approval of a service
plan granted to a specific individual and a homecare worker to exceed the limitations
as described in OAR 411-030-0070(6) based upon the service needs of the individual
as determined by the Department.
(d) "Exceptional rate" or
"exceptional payment." The approval of an exception is based on the service needs
of the individual and is contingent upon the individual's service plan meeting the
requirements in OAR 411-027-0020, 411-027-0025, and 411-027-0050.
(25) "FICA" is the acronym
for the Social Security payroll taxes collected under authority of the Federal Insurance
Contributions Act.
(26) "Financial Accountability"
refers to guidance and oversight which act as fiscal safeguards to identify budget
problems on a timely basis and allow corrective action to be taken to protect the
health and welfare of individuals.
(27) "FUTA" is the acronym
for Federal Unemployment Tax Assessment which is a United States payroll (or employment)
tax imposed by the federal government on both employees and employers.
(28) "Homecare Worker" means
a provider, as described in OAR 411-031-0040, that is directly employed by a consumer
to provide either hourly or live-in services to the eligible consumer.
(a) The term homecare worker
includes:
(A) A consumer-employed provider
in the Spousal Pay and Oregon Project Independence Programs;
(B) A consumer-employed provider
that provides state plan personal care services to individuals; and
(C) A relative providing
Medicaid in-home services to an individual living in the relative’s home.
(b) The term homecare worker
does not include an Independent Choices Program provider or a personal support worker
enrolled through Developmental Disability Services or the Addictions and Mental
Health Division.
(29) "Hourly Services" mean
the in-home services, including activities of daily living and instrumental activities
of daily living, that are provided at regularly scheduled times not including live-in
services.
(30) "IADL" means "instrumental
activities of daily living" as defined in this rule.
(31) "ICP" means "Independent
Choices Program" as defined in this rule.
(32) "Independent Choices
Program (ICP)" means a self-directed in-home services program in which a participant
is given a cash benefit to purchase goods and services identified in the participant's
service plan and prior approved by the Department or Area Agency on Aging.
(33) "Individual" means a
person age 65 or older, or an adult with a physical disability, applying for or
eligible for services.
(34) "Individualized Back-Up
Plan" means a plan incorporated into an Independent Choices Program service plan
to address critical contingencies or incidents that pose a risk or harm to a participant's
health and welfare.
(35) "In-Home Services" mean
the activities of daily living and instrumental activities of daily living that
assist an individual to stay in his or her own home or the home of a relative.
(36) "Instrumental Activities
of Daily Living (IADL)" mean those activities, other than activities of daily living,
required by an individual to continue independent living. The definitions and parameters
for assessing needs in IADL are identified in OAR 411-015-0007.
(37) "Liability" refers to
the dollar amount an individual with excess income contributes to the cost of service
pursuant to OAR 461-160-0610 and 461-160-0620.
(38) "Live-In Services" mean
services provided when an individual requires and receives assistance with activities
of daily living and instrumental activities of daily living throughout a 24-hour
work period by one homecare worker.
(39) "Medicaid OHP Plus Benefit
Package" means only the Medicaid benefit packages provided under OAR 410-120-1210(4)(a)
and (b). This excludes individuals receiving Title XXI benefits.
(40) "Natural Supports" or
"Natural Support System" means resources and supports (e.g. relatives, friends,
neighbors, significant others, roommates, or the community) who are willing to voluntarily
provide services to an individual without the expectation of compensation. Natural
supports are identified in collaboration with the individual and the potential "natural
support". The natural support is required to have the skills, knowledge, and ability
to provide the needed services and supports.
(41) "Oregon Project Independence
(OPI)" means the program of in-home services described in OAR chapter 411, division
32.
(42) "Participant" means
an individual eligible for the Independent Choices Program.
(43) "Provider" means the
person who renders the services.
(44) "Rate Schedule" means
the rate schedule maintained by the Department at http://www.dhs.state.or.us/spd/tools/program/osip/rateschedule.pdf.
Printed copies may be obtained by calling (503) 945-6398 or writing the Department
of Human Services, Aging and People with Disabilities, ATTN: Rules Coordinator,
500 Summer Street NE, E-48, Salem, Oregon 97301-1064.
(45) "Relative" means a person,
excluding an individual's spouse, who is related to the individual by blood, marriage,
or adoption.
(46) "Representative" is
a person either appointed by an individual to participate in service planning on
the individual's behalf or an individual's natural support with longstanding involvement
in assuring the individual's health, safety, and welfare. There are additional responsibilities
for an Independent Choices Program (ICP) representative as described in OAR 411-030-0100.
An ICP representative is not a paid employee provider regardless of relationship
to a participant.
(47) "Service Budget" means
a participant’s plan for the distribution of authorized funds that are under
the control and direction of the participant within the Independent Choices Program.
A service budget is a required component of the participant's service plan.
(48) "Service Need" means
the assistance an individual requires from another person for those functions or
activities identified in OAR 411-015-0006 and 411-015-0007.
(49) "Shift Services" are
hourly services provided by an awake homecare worker, Independent Choices Program
employee provider, or contracted in-home care agency provider to an individual who
is authorized to receive a minimum of 16 hours (496 hours per month) during a 24-hour
work period.
(50) "Spouse" means a person
that is legally married to an individual as defined in OAR 461-001-0000.
(51) "SUTA" is the acronym
for State Unemployment Tax Assessment. State unemployment taxes are paid by employers
to finance the unemployment benefit system that exists in each state.
(52) "These Rules" mean the
rules in OAR chapter 411, division 30.
(53) "Workweek" is defined
as 12:00 a.m. on Sunday through 11:59 p.m. on Saturday.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: SSD 5-1983, f. 6-7-83,
ef. 7-1-83; SSD 3-1985, f. & ef. 4-1-85; SSD 5-1987, f. & ef. 7-1-87; SSD
4-1993, f. 4-30-93, cert. ef. 6-1-93; SSD 6-1994, f. & cert. ef. 11-15-94; SPD
14-2003, f. & cert. ef. 7-31-03; SPD 15-2003 f. & cert. ef. 9-30-03; SPD
18-2003(Temp), f. & cert. ef. 12-11-03 thru 6-7-04; SPD 15-2004, f. 5-28-04,
cert. ef. 6-7-04; SPD 18-2005(Temp), f. 12-20-05, cert. ef. 12-21-05 thru 6-1-06;
SPD 20-2006, f. 5-26-06, cert. ef. 6-1-06; SPD 3-2007(Temp), f. 4-11-07, cert. ef.
5-1-07 thru 10-28-07; SPD 17-2007, f. 10-26-07, cert. ef. 10-28-07; SPD 4-2008(Temp),
f. & cert. ef. 4-1-08 thru 9-24-08; SPD 13-2008, f. & cert. ef. 9-24-08;
SPD 15-2008, f. 12-26-08, cert. ef. 1-1-09; SPD 10-2013(Temp), f. & cert. ef.
5-23-13 thru 11-19-13; SPD 16-2013(Temp), f. & cert. ef. 7-1-13 thru 11-19-13;
SPD 43-2013, f. 10-31-13, cert. ef. 11-1-13; APD 9-2014(Temp), f. 4-17-14, cert.
ef. 4-21-14 thru 10-18-14; APD 35-2014, f. & cert. ef. 10-1-14; APD 19-2015(Temp),
f. & cert. ef. 9-21-15 thru 3-18-16
411-030-0033
In-Home Service
Living Arrangements
(1) The following terms are used in
this rule:
(a) "Informal arrangement"
means a paid or unpaid arrangement for shelter or utility costs that does not include
the elements of a property manager's rental agreement.
(b) "Property manager's rental
agreement" means a payment arrangement for shelter or utility costs with a property
owner, property manager, or landlord that includes all of the following elements:
(A) The name and contact
information for the property manager, landlord, or leaser;
(B) The period or term of
the agreement and method for terminating the agreement;
(C) The number of tenants
or occupants;
(D) The rental fee and any
other charges (such as security deposits);
(E) The frequency of payments
(such as monthly);
(F) What costs are covered
by the amount of rent charged (such as shelter, utilities, or other expenses); and
(G) The duties and responsibilities
of the property manager and the tenant, such as:
(i) The person responsible
for maintenance;
(ii) If the property is furnished
or unfurnished; and
(iii) Advance notice requirements
prior to an increase in rent
(c) "Provider-owned dwelling"
means a dwelling that is owned by a provider or the provider's spouse when the provider
is proposing to be paid for Medicaid home and community-based services and the provider
or the provider’s spouse is not related to an individual by blood, marriage,
or adoption. Provider-owned dwellings include, but are not limited to:
(A) Houses, apartments, and
condominiums;
(B) A portion of a house
such as basement or a garage even when remodeled to be used as a separate dwelling;
(C) Trailers and mobile homes;
or
(D) Duplexes, unless the
structure displays a separate address from the other residential unit and was originally
built as a duplex.
(d) "Provider-rented dwelling"
means a dwelling that is rented or leased by a provider or the provider's spouse
when the provider is proposing to be paid for Medicaid home and community-based
services and the provider or the provider’s spouse is not related to an individual
by blood, marriage, or adoption.
(2) An individual is eligible
for Medicaid in-home services if the individual:
(a) Resides in a dwelling
the individual owns or rents;
(b) Resides in a provider-owned
or provider-rented dwelling and the individual's name is added to the property deed,
mortgage, title, or property manager's rental agreement; or
(c) Resides, either through
an informal arrangement or property manager’s rental agreement, in a dwelling
owned or rented by a relative as defined in OAR 411-030-0020.
(3) An individual is not
eligible for Medicaid in-home services if the individual resides in a provider-owned
or rented dwelling through an informal arrangement. A provider-owned or rented dwelling
may meet the requirements for a limited adult foster home as described in OAR 411-050-0405.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: SSD 4-1993, f. 4-30-93,
cert. ef. 6-1-93; SPD 14-2003, f. & cert. ef. 7-31-03; SPD 15-2003 f. &
cert. ef. 9-30-03; SPD 18-2003(Temp), f. & cert. ef. 12-11-03 thru 6-7-04; SPD
15-2004, f. 5-28-04, cert. ef. 6-7-04; SPD 18-2005(Temp), f. 12-20-05, cert. ef.
12-21-05 thru 6-1-06; SPD 20-2006, f. 5-26-06, cert. ef. 6-1-06; SPD 15-2008, f.
12-26-08, cert. ef. 1-1-09; SPD 10-2013(Temp), f. & cert. ef. 5-23-13 thru 11-19-13;
SPD 43-2013, f. 10-31-13, cert. ef. 11-1-13
411-030-0040
Eligibility Criteria
(1) In-home services are provided to
individuals who meet the established priorities for service as described in OAR
chapter 411, division 015 who have been assessed to be in need of in-home services.
(a) Payments for in-home
services are not intended to replace the resources available to an individual from
the individual's natural supports.
(b) An individual whose service
needs are sufficiently and appropriately met by available natural supports is not
eligible for in-home services.
(2) An individual receiving
Medicaid in-home services must:
(a) Meet the established
priorities for service as described in OAR chapter 411, division 015;
(b) Meet all the eligibility
requirements in 411-015-0010 through 411-015-0100; and(c) Reside in a living arrangement
described in OAR 411-030-0033;
(3) An individual receiving
services through the Independent Choices Program must:
(a) Meet the established
priorities for service as described in OAR chapter 411, division 015;
(b) Be a current recipient
of OSIPM (Oregon Supplemental Income Program Medical).
(c) Reside in a living arrangement
described in OAR 411-030-0033; and
(d) Be 18 years of age or
older.
(4) To be eligible for Medicaid
in-home services, an individual must employ an enrolled homecare worker or contracted
in-home care agency. To be eligible for ICP, a participant must employ an employee
provider.
(5) Initial eligibility for
Medicaid in-home services, or the ICP, does not begin until an individual's service
plan has been authorized by the Department or the Department’s designee. The
service plan must identify the provider who delivers the authorized services, include
the date when the provision of services begins, and include the maximum number of
hours authorized. Service plans must be based upon the least costly means of providing
adequate services.
(6) If, for any reason, the
employment relationship between an individual and provider is discontinued, an enrolled
homecare worker or contracted in-home care agency must be employed within 14 business
days for the individual to remain eligible for in-home services. A participant of
ICP must employ an employee provider within 14 business days to remain eligible
for ICP services. The individual’s case manager has the authority to waive
the 14 business day restriction if the individual is making progress towards employing
a provider.
(7) An eligible individual
who has been receiving in-home services who temporarily enters a nursing facility
or medical institution must employ an enrolled homecare worker or contracted in-home
care agency within 14 business days of discharge from the facility or institution
for the individual to remain eligible for in-home services. A participant of ICP
must employ an employee provider within 14 business days of discharge to remain
eligible for ICP services.
(8) EMPLOYER RESPONSIBILITIES.
(a) In order to be eligible
for in-home services provided by a homecare worker, an individual must be able to,
or designate a representative to:
(A) Locate, screen, and hire
a qualified homecare worker;
(B) Supervise and train the
homecare worker;
(C) Schedule the homecare
worker's work, leave, and coverage;
(D) Track the hours worked
and verify the authorized hours completed by the homecare worker;
(E) Recognize, discuss, and
attempt to correct any performance deficiencies with the homecare worker; and
(F) Discharge an unsatisfactory
homecare worker.
(b) Individuals who are unable
to meet the responsibilities in subsection (a) of this section are ineligible for
in-home services provided by a homecare worker. Except as set forth in subsection
(f) of this section, individuals ineligible for in-home services provided by a homecare
worker may designate a representative to manage the individual’s responsibilities
as an employer on the individual’s behalf. A representative of an individual
may not be a homecare worker providing homecare worker services to the individual.
Individuals must also be offered other available community-based service options
to meet the individual’s service needs, including contracted in-home care
agency services, nursing facility services, or other community-based service options.
(c) An individual determined
ineligible for in-home services provided by a homecare worker and who does not have
a representative may request in-home services provided by a homecare worker at the
individual's next re-assessment, but no sooner than 12 months from the date the
individual was determined ineligible. To reestablish eligibility for in-home services
provided by a homecare worker, an individual must attend training and acquire, or
otherwise demonstrate, the ability to meet the employer responsibilities in subsection
(a) of this section. Improvements in health and cognitive functioning, for example,
may be factors in demonstrating the individual's ability to meet the employer responsibilities
in subsection (a) of this section. If the Department determines an individual may
not meet the individual’s employer responsibilities, the Department may require
the individual appoint an acceptable representative.
(d) The Department retains
the right to approve the representative selected by an individual. Approval may
be based on, but is not limited to, the representative’s criminal history,
protective services history, or credible allegations of fraud or collusion in fraudulent
activities involving a public assistance program.
(e) If an individual’s
designated representative is unable to meet the employer responsibilities of subsection
(a) of this section, or the Department does not approve the representative, the
individual must designate a different representative or select other available services.
(f) An individual with a
history of credible allegations of fraud or collusion in fraud with respect to in-home
services is not eligible for in-home services provided by a homecare worker.
(9) REPRESENTATIVE.
(a) The Department, or the
Department’s designee, may deny an individual’s request for any representative
if the representative has a history of a substantiated adult protective service
complaint as described in OAR chapter 411, division 020. The individual may select
another representative.
(b) An individual with a
guardian must have a representative for service planning purposes. A guardian may
designate themselves as the representative.
(10) Additional eligibility
criteria for Medicaid in-home services exist for individuals eligible for:
(a) The Consumer-Employed
Provider Program as described in OAR chapter 411, division 031;
(b) The Independent Choices
Program as described in OAR 411-030-0100 of these rules; and
(c) The Spousal Pay Program
as described in OAR 411-030-0080 of these rules.
(11) Residents of licensed
community-based care facilities, nursing facilities, prisons, hospitals, and other
institutions that provide assistance with ADLs, are not eligible for in-home services.
(12) Individuals with excess
income must contribute to the cost of service pursuant to OAR 461-160-0610 and 461-160-0620.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: SSD 3-1985, f. &
ef. 4-1-85; SSD 4-1993, f. 4-30-93, cert. ef. 6-12-93, Renumbered from 411-030-0001;
SPD 2-2003(Temp), f. 1-31-03, cert. ef. 2-1-03 thru 7-30-03; SPD 14-2003, f. &
cert. ef. 7-31-03; SPD 15-2003 f. & cert. ef. 9-30-03; SPD 18-2003(Temp), f.
& cert. ef. 12-11-03 thru 6-7-04; SPD 15-2004, f. 5-28-04, cert. ef. 6-7-04;
SPD 18-2005(Temp), f. 12-20-05, cert. ef. 12-21-05 thru 6-1-06; SPD 1-2006(Temp),
f. & cert. ef. 1-13-06 thru 6-1-06; SPD 20-2006, f. 5-26-06, cert. ef. 6-1-06;
SPD 4-2008(Temp), f. & cert. ef. 4-1-08 thru 9-24-08; SPD 13-2008, f. &
cert. ef. 9-24-08; SPD 15-2008, f. 12-26-08, cert. ef. 1-1-09; SPD 10-2013(Temp),
f. & cert. ef. 5-23-13 thru 11-19-13; SPD 43-2013, f. 10-31-13, cert. ef. 11-1-13;
APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14; APD 35-2014, f. &
cert. ef. 10-1-14; APD 49-2014(Temp), f. 12-30-14, cert. ef. 1-1-15 thru 6-29-15;
APD 9-2015, f. 3-30-15, cert. ef. 4-3-15
411-030-0050
Case Management
(1) ASSESSMENT. The assessment process
identifies an individual's ability to perform ADLs, IADLs, and determines an individual's
ability to address health and safety concerns.
(a) The case manager must
conduct an assessment in accordance with the standards of practices established
by the Department in OAR 411-015-0008.
(b) The assessment must be
conducted by a case manager or other qualified Department or AAA representative
with a standardized assessment tool approved by the Department in the home of the
eligible individual, no less than annually.
(2) PERSON-CENTERED SERVICE
PLANNING.
(a) An individual and the
individual's case manager, with the assistance of others involved, must consider
in-home service options as well as assistive devices, architectural modifications,
and other community-based resources to meet the service needs identified in the
assessment process.
(A) The individual or the
individual's representative is responsible for choosing and assisting in developing
less costly service alternatives, including the Consumer-Employed Provider Program
and contracted in-home care agency services.
(B) The case manager is responsible
for:
(i) Determining eligibility
for specific services;
(ii) Presenting service options,
resources, and alternatives to the individual to assist the individual in making
informed choices and decisions;
(iii) Identifying risks;
(iv) Assisting the individual
with developing backup plans;
(v) Identifying the individual’s
goals and preferences;
(vi) Assessing the cost effectiveness
of the individual's service plan; and
(vii) Developing a person-centered
service plan.
(C) The case manager must
monitor the service plan and make adjustments as needed.
(b) The Department takes
necessary safeguards to protect an individual's health, safety, and welfare in implementing
an individual's service plan in accordance with 42 CFR 441.302 and 42 CFR 441.570.
When an individual with the ability to make an informed decision selects a service
choice that jeopardizes health and safety, the Department or AAA staff shall offer
or recommend options to the individual in order to minimize those risks. For the
purpose of this rule, an "informed decision" means the individual understands the
benefits, risks, and consequences of the service choice selected. Options that minimize
risks may include offering or recommending:
(A) Natural supports to provide
assistance with safety or health emergencies;
(B) An emergency response
system;
(C) A back-up plan for assistance
with service needs;
(D) Resources for emergency
disaster planning;
(E) A referral for long term
care community nursing services;
(F) Resources for provider
and consumer training;
(G) Assistive devices; or
(H) Architectural modifications.
(c) The Department or AAA
may not authorize a service provider, service setting, or a combination of services
selected by an eligible individual or the individual's representative when:
(A) The service setting has
dangerous conditions that jeopardize the health or safety of the individual and
necessary safeguards cannot be taken to improve the setting;
(B) Services cannot be provided
safely or adequately by the service provider based on:
(i) The extent of the individual's
service needs; or
(ii) The choices or preferences
of the eligible individual or the individual's representative;
(C) Dangerous conditions
in the service setting jeopardize the health or safety of the service provider that
is authorized and paid for by the Department, and necessary safeguards cannot be
taken to minimize the dangers; or
(D) 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 the Department or AAA cannot take necessary
safeguards to protect the safety, health, and welfare of the individual.
(d) The case manager must
present the individual or the individual's representative with information on service
alternatives and provide assistance to assess other choices when the service provider
or service setting selected by the individual or the individual's representative
is not authorized.
(3) PAYMENT.
(a) The service plan payment
is considered full payment for Medicaid home and community-based services rendered.
Under no circumstances is the service provider to demand or receive additional payment
for these services from the consumer or any other source.
(b) Additional payment to
homecare workers or ICP employee providers for the same services covered by Medicaid
in-home services or the Spousal Pay Program is prohibited.
(c) For ICP, the service
plan must include the service budget as described in OAR 411-030-0100.
(d) For service plans in
which a consumer lives in the relative homecare workers home, subsection (a) of
this section does not apply to rent and living expenses.
(4) HARDSHIP SHELTER ALLOWANCE.
The Department may not authorize a hardship shelter allowance associated with employing
a live-in provider on or after June 1, 2006. Individuals eligible for and authorized
to receive a hardship shelter allowance before June 1, 2006 may continue to receive
a hardship shelter allowance on or after June 1, 2006 at the rate established by
the Department if one of the following conditions is met:
(a) The individual is forced
to move from their current dwelling and the individual's current average monthly
rent or mortgage costs exceed current OSIP and OSIPM standards for a one-person
need group as outlined in OAR 461-155-0250; or
(b) Service costs significantly
increase as a result of the individual being unable to provide living quarters for
a necessary live-in provider.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: SSD 5-1983, f. 6-7-83,
ef. 7-1-83; SSD 3-1985, f. & ef. 4-1-85; SSD 12-1985(Temp), f. & ef. 9-19-85;
SSD 16-1985, f. 12-31-85, ef. 1-1-86; SSD 4-1987(Temp), f. & ef. 7-1-87; SSD
1-1988, f. & cert. ef. 3-1-88; SSD 6-1988, f. & cert. ef. 7-1-88; SSD 9-1989,
f. 6-30-89, cert. ef. 7-1-89; SSD 11-1989(Temp), f. & cert. ef. 9-1-89; SSD
18-1989, f. 12-29-89, cert. ef. 1-1-90; SSD 7-1990(Temp), f. & cert. ef. 3-1-90;
SSD 16-1990, f. & cert. ef. 8-20-90; SSD 1-1992, f. & cert. ef. 2-21-92;
SSD 4-1993, f. 4-30-93, cert. ef. 6-1-93, Renumbered from 411-030-0022; SPD 14-2003,
f. & cert. ef. 7-31-03; SPD 15-2003 f. & cert. ef. 9-30-03; SPD 15-2004,
f. 5-28-04, cert. ef. 6-7-04; SPD 18-2005(Temp), f. 12-20-05, cert. ef. 12-21-05
thru 6-1-06; SPD 20-2006, f. 5-26-06, cert. ef. 6-1-06; SPD 4-2008(Temp), f. &
cert. ef. 4-1-08 thru 9-24-08; SPD 13-2008, f. & cert. ef. 9-24-08; SPD 15-2008,
f. 12-26-08, cert. ef. 1-1-09; SPD 10-2013(Temp), f. & cert. ef. 5-23-13 thru
11-19-13; SPD 43-2013, f. 10-31-13, cert. ef. 11-1-13
411-030-0055
Service-Related Transportation
(1) Community transportation (non-medical)
may be prior-authorized for reasons related to an eligible individual's safety or
health, in accordance with the individual's service plan. Community transportation
is offered through contracted transportation providers or by homecare workers.
(2) Community transportation
may be authorized to assist an eligible individual in getting to and from the individual's
place of employment when the individual is approved for the Employed Persons with
Disabilities Program (OSIPM-EPD).
(3) Natural supports, volunteer
transportation, and other transportation services available to an eligible individual
are considered a prior resource and may not be replaced with transportation paid
for by the Department.
(4) DMAP is a resource for
medical transportation to a physician, hospital, clinic, or other medical service
provider. Medical transportation costs are not reimbursed through community transportation.
(5) Community transportation
is not provided by the Department to obtain medical or non-medical items that may
be delivered by a supplier or sent by mail order without cost to the eligible individual.
(6) Community transportation
must be prior authorized by an individual's case manager and documented in the individual's
service plan. 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 Department
or AAA and documented in the individual's service plan.
(a) Contracted transportation
providers are reimbursed according to the terms of their contract with the Department.
Community transportation services provided through contracted transportation providers
must be authorized by a case manager based on an estimate of a total count of one
way rides per month.
(b) Homecare workers who
use their own personal vehicle for community transportation are reimbursed according
to the terms defined in their Collective Bargaining Agreement between the Home Care
Commission and Service Employees International Union, Local 503, OPEU. Any mileage
reimbursement authorized to a homecare worker must be based on an estimate of the
monthly maximum miles required to drive to and from the destination authorized in
an individual's service plan. Community transportation hours are authorized in accordance
with OAR 411-030-0070.
(c) The Department or AAA
does not authorize reimbursement for travel to or from the residence of a homecare
worker. The Department or AAA only authorizes community transportation and mileage
from the home of an eligible individual to the destination authorized in the individual's
service plan and back to the individual's home.
(7) The Department is not
responsible for any vehicle damage or personal injury sustained while using a personal
motor vehicle for community transportation.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: SPD 18-2005(Temp),
f. 12-20-05, cert. ef. 12-21-05 thru 6-1-06; SPD 20-2006, f. 5-26-06, cert. ef.
6-1-06; SPD 15-2008, f. 12-26-08, cert. ef. 1-1-09; SPD 10-2013(Temp), f. &
cert. ef. 5-23-13 thru 11-19-13; SPD 43-2013, f. 10-31-13, cert. ef. 11-1-13
411-030-0068
Live-In Services and Shift Services
(1) Individuals with service plans that
meet the definition of live-in services or shift services must meet subsections
(a) and either (b) or (c) of this section of the rule.
(a) The provision of assistance
with at least one ADL or IADL task must be required sometime during each hour the
individual is awake in order to ensure the safety and well-being of the individual.
(b) The individual is assessed
as full assist in mobility or elimination as defined in OAR 411-015-0006, and has
at least one of the following conditions:
(A) A debilitating medical
condition that includes, but is not limited to, any of the following symptoms:
(i) Cachexia;
(ii) Severe neuropathy;
(iii) Coma;
(iv) Persistent or reoccurring
stage 3 or 4 wounds;
(v) Late stage cancer;
(vii) Frequent and unpredictable
seizures; or
(viii) Debilitating muscle
spasms.
(B) A spinal cord injury
or similar disability with permanent impairment.
(C) An acute care or hospice
need that is expected to last no more than six months.
(c) The individual is assessed
as full assist in cognition as defined in OAR 411-015-0006 and meets all of the
following criteria:
(A) A diagnosis of traumatic
brain injury, dementia or a related disorder, or a debilitating mental health disorder
that meets the criteria described in OAR 411-015-0015(2).
(B) Has one of the following
assessed needs as defined in OAR 411-015-0006:
(i) Full assist in danger
to self or others.
(ii) Full assist in wandering.
(iii) Full assist in awareness,
or
(iv) Full assist in judgment.
(2) The following limitations
apply:
(a) A homecare worker providing
live-in services must be available to address the service needs of an eligible individual
as they arise throughout an entire 24-hour period. A homecare worker is not providing
live-in services if the homecare worker is outside the individual's home or building
during the homecare worker's on-duty hours and the homecare worker engages in activities
that are unrelated to the provision of the individual's ADL or IADL services and
supports. A homecare worker is not providing live-in services if they are offsite
and are not performing direct ADL or IADL services.
(b) Hourly services by another
home care worker or contracted in-home agency may be authorized in addition to live-in
services for a documented need for the service only. This includes any task that
requires more than one homecare worker to simultaneously perform the task, or to
allow a live-in home care worker to sleep for at least five continuous hours during
a 24-hour work period.
(c) A homecare worker who
is providing live-in services for an individual may not also provide hourly services
for the same individual.
(3) Individuals with assessments
that were created prior to August 31, 2015 may continue receiving live-in services
or shift services until one of the following occurs:
(a) The individual moves
from an in-home setting that does not meet the requirements of OAR 411-030-0033
for more than 30 days and later moves to an in-home setting that meets the requirements
of 411-030-0033. A new assessment and service plan must be completed to evaluate
and determine if the individual meets the criteria described in section (1) of this
rule.
(b) The individual ends their
live-in services or shift services for more than 30 days. A new assessment must
be completed to evaluate and determine if the individual meets the criteria described
in section (1) of this rule.
(c) A reassessment is created
on or after August 31, 2015 that requires a new service plan.
(4) If the individual chooses
to receive live-in or shift services, and the individual resides in an in-home setting
that meets the requirements of OAR 411-030-0033 on or after August 31, 2015, a reassessment
must be completed to evaluate and determine if the individual meets the criteria
described in section (1) of this rule.
(5) Individuals who currently
receive live-in services for at least 4 days a week, or are receiving hours under
24-hour services in the Independent Choices Program, and who are determined not
to meet the criteria for live-in services per section (1) of this rule after an
assessment created on or after August 31, 2015, may be granted an exception by Central
Office under the following circumstances:
(a) The individual must be
eligible for 159 hours of live-in services on the most recent assessment prior to
August 31, 2015, and be assessed as meeting one of the following as defined in OAR
415-015-0006:
(A) Full assist in mobility
and at least a substantial assist in ambulation or an assist in transfers.
(B) Full assist in cognition.
(C) Full assist in at least
two ADLs under elimination.
(b) Exceptions granted under
subsection (a) of this rule must end when the identified homecare worker per subsection
(a) of this rule or the primary provider under the Independent Choices Program is
no longer employed by the individual.
(6) An exception may be granted
by Central Office to authorize a live-in plan if an individual does not meet section
(1) of this rule to meet exceptional needs of the individual as defined by the Department.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: APD 19-2015(Temp),
f. & cert. ef. 9-21-15 thru 3-18-16
411-030-0070
Maximum Hours of Service
(1) LEVELS OF ASSISTANCE FOR DETERMINING
SERVICE PLAN HOURS.
(a) "Minimal Assistance"
means an individual is able to perform the majority of an activity but requires
some assistance from another person.
(b) "Substantial Assistance"
means an individual is able to perform only a small portion of the tasks that comprise
an activity without assistance from another person.
(c) "Full Assistance" means
an individual needs assistance from another person through all phases of an activity
every time the activity is attempted.
(2) MAXIMUM MONTHLY HOURS
FOR ADL.
(a) The planning process
uses the following limitations for time allotments for ADL tasks. Hours authorized
must be based on the service needs of an individual. Case managers may authorize
up to the amount of hours identified in these assistance levels (minimal, substantial,
or full assist).
(A) Eating:
(i) Minimal assistance, 5
hours;
(ii) Substantial assistance,
20 hours;
(iii) Full assistance, 30
hours.
(B) Dressing and Grooming:
(i) Minimal assistance, 5
hours;
(ii) Substantial assistance,
15 hours;
(iii) Full assistance, 20
hours.
(C) Bathing and Personal
Hygiene:
(i) Minimal assistance, 10
hours;
(ii) Substantial assistance,
15 hours;
(iii) Full assistance, 25
hours.
(D) Mobility:
(i) Minimal assistance, 10
hours;
(ii) Substantial assistance,
15 hours;
(iii) Full assistance, 25
hours.
(E) Elimination (Toileting,
Bowel, and Bladder):
(i) Minimal assistance, 10
hours;
(ii) Substantial assistance,
20 hours;
(iii) Full assistance, 25
hours.
(F) Cognition and Behavior:
(i) Minimal assistance, 5
hours;
(ii) Substantial assistance,
10 hours;
(iii) Full assistance, 20
hours.
(b) Service plan hours for
ADL may only be authorized for an individual if the individual requires assistance
(minimal, substantial, or full assist) from another person in that activity of daily
living as determined by a service assessment applying the parameters in OAR 411-015-0006.
(c) For households with two
or more eligible individuals, each individual's ADL service needs must be considered
separately. In accordance with section (3)(c) of this rule, authorization of IADL
hours is limited for each additional individual in the home.
(d) Hours authorized for
ADL are paid at the rates in accordance with the rate schedule. The Independent
Choices Program cash benefit is based on the hours authorized for ADLs paid at the
rates in accordance with the rate schedule. Participants of the Independent Choices
Program may determine their own employee provider pay rates, but must follow all
applicable wage and hour rules and regulations.
(3) MAXIMUM MONTHLY HOURS
FOR IADL.
(a) The planning process
uses the following limitations for time allotments for IADL tasks. Hours authorized
must be based on the service needs of an individual. Case managers may authorize
up to the amount of hours identified in these assistance levels (minimal, substantial,
or full assist).
(A) Medication and Oxygen
Management:
(i) Minimal assistance, 2
hours;
(ii) Substantial assistance,
4 hours;
(iii) Full assistance, 6
hours.
(B) Transportation or Escort
Assistance:
(i) Minimal assistance, 2
hours;
(ii) Substantial assistance,
3 hours;
(iii) Full assistance, 5
hours.
(C) Meal Preparation:
(i) Minimal assistance:
(I) Breakfast, 4 hours;
(II) Lunch, 4 hours;
(III) Supper, 8 hours.
(ii) Substantial assistance:
(I) Breakfast, 8 hours;
(II) Lunch, 8 hours;
(III) Supper, 16 hours.
(iii) Full assistance:
(I) Breakfast, 12 hours;
(II) Lunch, 12 hours;
(III) Supper, 24 hours.
(D) Shopping:
(i) Minimal assistance, 2
hours;
(ii) Substantial assistance,
4 hours;
(iii) Full assistance, 6
hours.
(E) Housecleaning:
(i) Minimal assistance, 5
hours.
(ii) Substantial assistance,
10 hours.
(iii) Full assistance, 20
hours.
(b) Hours authorized for
IADL are paid at the rates in accordance with the rate schedule. The Independent
Choices Program cash benefit is based on the hours authorized for IADLs paid at
the rates in accordance with the rate schedule. Participants of the Independent
Choices Program may determine their own employee provider pay rates, but must follow
all applicable wage and hour rules and regulations.
(c) When two or more individuals
eligible for IADL task hours live in the same household, the assessed IADL need
of each individual must be calculated. Payment is made for the highest of the allotments
and a total of four additional IADL hours per month for each additional individual
to allow for the specific IADL needs of the other individuals.
(d) Service plan hours for
IADL tasks may only be authorized for an individual if the individual requires assistance
(minimal, substantial, or full assist) from another person in that IADL task as
determined by a service assessment applying the parameters in OAR 411-015-0007.
(4) PAYMENT FOR LIVE-IN SERVICES.
(a) Payment for live-in services
is authorized only when an individual employs a live-in homecare worker or enrolls
in the Independent Choices Program and meets the requirements of OAR 411-030-0068.
Individuals who meet these criteria may be authorized 159 hours a month for the
provision of this service until December 31, 2015.
(b) Effective January 1,
2016, payment for live-in services is authorized only when an individual employs
a live-in homecare worker or enrolls in the Independent Choices Program and meets
the requirements of OAR 411-030-0068. Individuals that meet these criteria will
be authorized to receive 16 hours per day (496 hours per month). Additional hours
may be authorized, on a case by case basis, to meet the needs of the individual
during the hours of the homecare worker's scheduled sleep period if the homecare
worker’s scheduled sleep period is routinely disrupted.
(c) Rates for live-in services
are paid in accordance with the rate schedule.
(d) When a live-in homecare
worker is employed less than seven days per week, the total service hours must be
prorated.
(5) When one or more eligible
individuals in the same household is eligible for and receiving in-home services,
the amount of hours authorized is subject to the following maximums:
(a) Live-in service plans
may not exceed 19 hours per day (589 hours per month).
(b) Hourly and shift service
plans (which may also include a live-in service plan within the same household)
may not exceed 24 hours per day (744 hours per month).
(6) Beginning August 31,
2015, at the creation of a new service plan resulting from an assessment or when
a homecare worker begins employment with an individual, the following limitations
to the authorized hours a homecare worker may work will apply:
(a) Hourly or shift services
plan of no more than 220 hours per month or 50 hours per workweek per individual.
(b) Hourly or shift services
plan of no more than 16 hours during a 24-hour work period.
(7) A provider may not receive
payment from the Department for more than the total amount authorized by the Department
on the service plan authorization form under any circumstances. All service payments
must be prior-authorized by a case manager.
(8) Case managers must assess
and utilize as appropriate, natural supports, cost-effective assistive devices,
durable medical equipment, housing accommodations, and alternative service resources
(as defined in OAR 411-015-0005) that may reduce the need for paid assistance.
(9) The Department may authorize
paid in-home services only to the extent necessary to supplement potential or existing
resources within an individual's natural supports system.
(10) Payment by the Department
for Medicaid home and community-based services are only made for the tasks described
in this rule as ADL, IADL tasks, and live-in services. Services must be authorized
to meet the needs of an eligible individual and may not be provided to benefit an
entire household.
(11) EXCEPTIONS TO MAXIMUM
HOURS OF SERVICE.
(a) To meet an extraordinary
ADL service need that has been documented, the hours authorized for ADL may exceed
the full assistance hours (described in section (2) of this rule) as long as the
total number of ADL hours in the service plan does not exceed 145 hours per month.
(b) Monthly service payments
that exceed 145 ADL hours per month may be approved by the Department when the exceptional
payment criteria identified in OAR 411-027-0020 and 411-027-0050 is met.
(c) As long as the total
number of IADL task hours in the service plan does not exceed 85 hours per month
and the service need is documented, the hours authorized for IADL tasks may exceed
the hours for full assistance (as described in section (3) of this rule) for the
following tasks and circumstances:
(A) Housekeeping based on
medical need (such as immune deficiency);
(B) Short-term extraordinary
housekeeping services necessary to reverse unsanitary conditions that jeopardize
the health of an individual; or
(C) Extraordinary IADL needs
in medication management or service-related transportation.
(d) Monthly service plans
that exceed 85 hours per month in IADL tasks may be approved by the Department when
an individual meets the exceptional payment criteria identified in OAR 411-027-0020
and 411-027-0050.
(e) One or more individuals
in the same household may exceed the maximums in section (5) of this rule in the
following circumstances:
(A) The service plan authorizes
payment that requires the assistance of more than one homecare worker to simultaneously
perform a specific task.
(B) The ADLs of two or more
individuals in the same household require a homecare worker for each individual
at the same time.
(f) A homecare worker may
be authorized to provide services totaling more than 220 hours per month or 50 hours
per workweek per individual if they are prior authorized by the Department. In emergency
situations, when the Department is not available, a homecare worker may work critical
hours, but must notify the Department within two business days.
(g) A homecare worker may
be authorized by the Department to work more than 16 hours of hourly services during
a 24-hour work period if an unanticipated need arises that requires the homecare
worker to remain awake in order to provide the necessary care.
[ED. NOTE: Forms referenced are available
from the agency.]
Stat. Auth.: ORS 409.050,
410.070 & 410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: SSD 4-1993, f. 4-30-93,
cert. ef. 6-1-93; SSD 6-1994, f. & cert. ef. 11-15-94; SDSD 8-1999(Temp), f.
& cert. ef. 10-15-99 thru 4-11-00; SDSD 3-2000, f. 4-11-00, cert. ef. 4-12-00;
SPD 14-2003, f. & cert. ef. 7-31-03; SPD 15-2003 f. & cert. ef. 9-30-03;
SPD 15-2004, f. 5-28-04, cert. ef. 6-7-04; SPD 15-2004, f. 5-28-04, cert. ef. 6-7-04;
SPD 18-2005(Temp), f. 12-20-05, cert. ef. 12-21-05 thru 6-1-06; SPD 20-2006, f.
5-26-06, cert. ef. 6-1-06; SPD 4-2008(Temp), f. & cert. ef. 4-1-08 thru 9-24-08;
SPD 13-2008, f. & cert. ef. 9-24-08; SPD 15-2008, f. 12-26-08, cert. ef. 1-1-09;
SPD 24-2011(Temp), f. 11-15-11, cert. ef. 1-1-12 thru 6-29-12; SPD 6-2012, f. 5-31-12,
cert. ef. 6-1-12; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD
44-2013, f. 12-13-13, cert. ef. 12-15-13; APD 11-2014, f. & cert. ef. 5-1-14;
APD 19-2015(Temp), f. & cert. ef. 9-21-15 thru 3-18-16
411-030-0080
Spousal Pay Program
(1) The Spousal Pay Program is one of
the hourly service options under in-home services for those who qualify.
(2) ELIGIBILITY. An individual
may be eligible for the Spousal Pay Program when all of the following conditions
are met:
(a) The individual has met
all eligibility requirements for in-home services as described in OAR 411-030-0040;
(b) The individual requires
full assistance in at least four of the six ADLs described in OAR 411-015-0006 as
determined by the assessment described in OAR chapter 411, division 015;
(c) The individual has met
all eligibility requirements as described in OAR 411-030-0068 section (1)(b).
(d) The individual would
otherwise require nursing facility services without Medicaid in-home services;
(e) The individual’s
service needs exceed in both extent and duration the usual and customary services
rendered by one spouse to another;
(f) The spouse demonstrates
the capability and health to provide the services and actually provides the principal
services, including the majority of service plan hours, for which payment has been
authorized;
(g) The spouse meets all
requirements for enrollment as a homecare worker in the Consumer-Employed Provider
Program as described in OAR 411-031-0040; and
(h) The Department has reviewed
the request and approved program eligibility at enrollment and annually upon re-assessment.
(3) PAYMENTS.
(a) All payments must be
prior authorized by the Department or the Department's designee.
(b) The hours authorized
to the spousal pay provider in an individual's service plan must consist of one-half
of the assessed hours for IADLs and all of the hours for specific ADLs based on
the service needs of the individual. Service plans that authorize a spousal pay
provider are not eligible for live-in services.
(c) Except as described otherwise
in subsection (d) of this section, spousal pay providers are paid at hourly homecare
worker rates for ADLs and IADLs as defined in the rate schedule.
(d) Homecare workers who
marry their consumer-employer retain the same standard of compensation, if their
employer meets the spousal pay eligibility criteria as described in section (3)
of this rule. Additional IADL hours may be authorized in the service plan when necessary
to prevent a loss of compensation to the homecare worker following marriage to the
consumer-employer.
(e) Spousal pay providers
may not claim payment from the Department for hours that the spousal pay provider
did not work.
(4) Spousal pay providers
are subject to the provisions in OAR chapter 411, division 031 governing homecare
workers enrolled in the Consumer-Employed Provider Program.
(5) Individuals receiving
Spousal Pay Program services who have excess income must contribute to the cost
of services pursuant to OAR 461-160-0610 and 461-160-0620.
(6) All Spousal Pay Program
service plans with live-in hours in effect prior to January 1, 2016 will transition
to hourly plans by January 1, 2016.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020, 410.070, 411.802 & 411.803
Hist.: SSD 4-1984, f. 4-27-84,
ef. 5-1-84; SSD 3-1985, f. & ef. 4-1-85; SSD 4-1993, f. 4-30-93, cert. ef. 6-1-93,
Renumbered from 411-030-0027; SDSD 2-2000, f. 3-27-00, cert. ef. 4-1-00; SPD 2-2003(Temp),
f. 1-31-03, cert. ef. 2-1-03 thru 7-30-03; SPD 14-2003, f. & cert. ef. 7-31-03;
SPD 15-2003 f. & cert. ef. 9-30-03; SPD 15-2004, f. 5-28-04, cert. ef. 6-7-04;
SPD 20-2006, f. 5-26-06, cert. ef. 6-1-06; SPD 3-2007(Temp), f. 4-11-07, cert. ef.
5-1-07 thru 10-28-07; SPD 17-2007, f. 10-26-07, cert. ef. 10-28-07; SPD 15-2008,
f. 12-26-08, cert. ef. 1-1-09; SPD 13-2012(Temp), f. & cert. ef. 9-26-12 thru
3-25-13; SPD 4-2013, f. 3-25-13, cert. ef. 3-26-13; SPD 10-2013(Temp), f. &
cert. ef. 5-23-13 thru 11-19-13; SPD 43-2013, f. 10-31-13, cert. ef. 11-1-13; APD
19-2015(Temp), f. & cert. ef. 9-21-15 thru 3-18-16
411-030-0090
Contracted In-Home Care Agency Services
(1) Contracted in-home care agency services
are one of the in-home service options for individuals eligible for Medicaid in-home
services.
(2) In-home care agencies
must be licensed in accordance with OAR chapter 333, division 536. The geographic
service area in which the agency provides services must comply with OAR 333-536-0050.
The specific services provided must be described in each contracted in-home care
agency's statement of work.
Stat. Auth.: ORS 409.050, 410.070 &
410.090
Stats. Implemented: ORS 410.010,
410.020 & 410.070
Hist.: SSD 4-1993, f. 4-30-93,
cert. ef. 6-1-93; SPD 14-2003, f. & cert. ef. 7-31-03; SPD 20-2006, f. 5-26-06,
cert. ef. 6-1-06; SPD 2-2007(Temp), f. & cert. ef. 3-30-07 thru 9-25-07; SPD
13-2007, f. 8-31-07, cert. ef. 9-4-07; SPD 15-2008, f. 12-26-08, cert. ef. 1-1-09;
SPD 10-2013(Temp), f. & cert. ef. 5-23-13 thru 11-19-13; SPD 43-2013, f. 10-31-13,
cert. ef. 11-1-13
411-030-0100
Independent Choices Program
(1) The Independent Choices Program
(ICP) is an In-Home Services Program that empowers participants to self-direct their
own service plans and purchase goods and services that enhance independence, dignity,
choice, and well-being.
(2) The ICP is limited to
a maximum of 2,600 participants.
(a) The Department establishes
and maintains a waiting list for individuals eligible for in-home services requesting
ICP after the ICP has reached its maximum.
(b) The Department enters
eligible individual’s names on the waiting list according to the date the
individual applied for participation in ICP.
(c) As vacancies occur, eligible
individuals on the waiting list are offered the ICP according to his or her place
on the waiting list.
(d) Individuals on the waiting
list may receive services through other appropriate Department programs for which
they are eligible.
(3) INITIAL ELIGIBILITY REQUIREMENTS.
(a) To be eligible for the
ICP an individual must:
(A) Meet all requirements
for in-home services as described in these rules;
(B) Develop a service plan
and budget to meet the needs identified in his or her CA/PS assessment;
(C) Sign the ICP participation
agreement;
(D) Have or be able to establish
a checking account;
(E) Provide evidence of a
stable living situation for the past three months; and
(F) Demonstrate the ability
to manage money as evidenced by timely and current utility and housing payments.
(b) If a participant is unable
to direct and purchase his or her own in-home services, the participant must have
a representative to act on the participant's behalf. The "representative" is the
person assigned by the participant to act as the participant's decision maker in
matters pertaining to the ICP service plan and service budget. A representative
must:
(A) Complete a background
check pursuant to OAR chapter 407, division 007 and receive a final fitness determination
of approval; and
(B) Sign and adhere to the
"Independent Choices Program Representative Agreement" on behalf of the participant.
(c) If a participant is unable
to manage ICP cash payment accounting, tax, or payroll responsibilities and does
not have a representative, the participant must arrange and purchase the ongoing
services of a fiscal intermediary, such as an accountant, bookkeeper, or equivalent
financial services.
(A) A participant, or the
participant's representative who has met the eligibility criteria in subsection
(b) of this section, may also choose to use a fiscal intermediary.
(B) The participant is responsible
for any fees or payment to the fiscal intermediary and may allocate the fees or
payment from discretionary or other non-ICP funds.
(4) DISENROLLMENT CRITERIA.
Participants may be disenrolled from the ICP voluntarily or involuntarily. Participants
who are disenrolled from the ICP may not reapply for six months. After the six month
disenrollment period, an individual may re-enroll and must meet all ICP eligibility
requirements. If the ICP enrollment cap has been reached, participants who were
disenrolled are added to the waiting list.
(a) VOLUNTARY DISENROLLMENT.
Participants or representatives must provide notice to the Department of intent
to discontinue participation in the ICP. The participant or the representative must
meet with the Department to reconcile remaining ICP cash payment either within 30
days of the date of disenrollment or before the termination date, whichever is sooner.
(b) INVOLUNTARY DISENROLLMENT.
The participant may be involuntarily disenrolled from the ICP when the participant,
representative, or employee provider does not adequately meet the participant's
service needs or carry out any of the following ICP responsibilities:
(A) Non-payment of employee’s
wages, as stated in the service budget.
(B) Failure to maintain the
participant's health and well-being by obtaining personal care as evidenced by:
(i) Decline in functional
status due to the failure to meet the participant’s needs; or
(ii) Substantiated complaints
of self-neglect, neglect, or other abuse on the part of the employee provider or
representative.
(C) Failure to purchase goods
and services according to the participant's service plan.
(D) Failure to comply with
the legal or financial obligations as an employer.
(E) Failure to maintain a
separate ICP checking account or commingling ICP cash benefit with other assets.
(F) Inability to manage the
cash benefit as evidenced by two or more incidents of overdrafts of the participant's
ICP checking account during the last cash benefit review period.
(G) Failure to deposit monthly
service liability payment into the ICP checking account.
(H) Failure to maintain an
individualized back-up plan (as part of the participant's service plan) resulting
in a negative consequence.
(I) Failure to sign or follow
the ICP Participation Agreement.
(J) Failure to select a representative
within 30 days if a participant needs a representative and does not have one.
(5) INTERRUPTION OF SERVICES.
The ICP cash benefit is terminated when a participant is absent from the home for
longer than 30 days due to illness or medical treatment. The cash benefit may resume
upon the participant's return to the home, providing ICP eligibility criteria is
met.
(6) SELECTION OF EMPLOYEE
PROVIDERS.
(a) The participant or representative
carries full responsibility for locating, screening, interviewing, hiring, training,
paying, and terminating employee providers. The participant or representative must
comply with Immigration and Customs Enforcement laws and policies.
(b) The participant or representative
must assure the employee provider's ability to perform or assist with ADL, IADL,
and live-in service needs.
(c) Employee providers must
complete a background check pursuant to OAR chapter 407, division 007. If a record
of a potentially disqualifying crime is revealed, the participant or representative
may employ the provider at the participant's or representative's discretion.
(d) A representative may
not be an employee provider regardless of relationship to the participant.
(e) A participant's relative
may be employed as an employee provider.
(7) CASH BENEFIT.
(a) The cash benefit is determined
based on the participant's CA/PS assessment of need, service plan, level of assistance
standards in OAR 411-030-0070, and natural supports.
(b) The cash benefit is calculated
by adding the ADL task hours, the IADL task hours, and the live-in services hours
that the participant is eligible for as determined in the CA/PS assessment, at the
rates according to the Department's rate schedule.
(c) The following services,
which are approved by the case manager and paid for by the Department, are excluded
from the ICP cash benefit:
(A) Long-term care community
nursing;
(B) Contracted community
transportation;
(C) Medicaid home delivered
meals; and
(D) Emergency response systems.
(d) The cash benefit includes
the employer’s portion of required FICA, FUTA, and SUTA.
(e) The cash benefit is directly
deposited into a participant's ICP designated checking account.
(8) SERVICE BUDGET.
(a) The service budget must
identify the cash benefit, the discretionary and contingency funds if applicable,
the reimbursement to an employee provider, and all other expenditures. The service
budget must be initially approved by a Department or AAA case manager.
(b) The participant may amend
the service budget as long as the amendments relate to meeting the participant's
service needs and are within ICP program guidelines.
(c) A budget review to assure
financial accountability and review service budget amendments must be completed
at least every six months.
(9) CONTINGENCY FUND.
(a) The participant may establish
a contingency fund in the service budget to purchase identified items that are not
otherwise covered by Medicaid or the Supplemental Nutrition Assistance Program (SNAP)
that substitute for personal assistance and allow for greater independence.
(b) The contingency fund
must be approved by the case manager, identified in the service budget, and related
to service plan needs.
(c) Contingency funds may
be carried over into the next month's budget until the item is purchased.
(10) DISCRETIONARY FUND.
(a) The participant may establish
a monthly discretionary fund in the service budget to purchase items that directly
relate to the health, safety, and independence of the participant and are not otherwise
covered under Medicaid home and community-based services or delineated in the monthly
service budget.
(b) The maximum amount of
discretionary funds may be up to 10 percent of the participant's cash benefit not
including employee taxes.
(c) The discretionary fund
must be approved by the case manager, identified in the service budget, and related
to service plan needs.
(d) Discretionary funds must
be used by the end of the month.
(11) ISSUING BENEFITS.
(a) The service plan and
service budget must be prior approved by the case manager before the first ICP cash
benefit is paid.
(b) A cash benefit is considered
issued and received by the participant when the direct deposit is made to the participant's
ICP bank account or a benefit check is received by the participant.
(c) The cash benefit is exempt
from resource calculations for other Department programs only while in the ICP bank
account and not commingled with other personal funds.
(d) The cash benefit is not
subject to assignment, transfer, garnishment, or levy as long as the cash benefit
is identified as a program benefit and is separate from other money in the participant's
possession.
(12) CASE MANAGER RESPONSIBILITIES.
(a) The case manager is responsible
to review and authorize service plans and service budgets that meet the ICP program
criteria.
(b) If a participant is disenrolled,
the case manager must review eligibility for other Medicaid long term care and community-based
service options and offer other alternatives if the participant is eligible.
(c) At least every six months,
a Department or AAA case manager must complete a service budget review to assure
financial accountability and review service budget amendments.
(13) HEARING RIGHTS. ICP
participants have contested case hearing rights as described in OAR chapter 461,
division 025.
(14) ICP eligible participants
who were determined eligible prior to August 31, 2015 may continue their current
service plan until a new assessment and service plan is completed.
Stat. Auth.: ORS 410.090
Stats. Implemented: ORS 410.070
Hist.: SPD 4-2008(Temp),
f. & cert. ef. 4-1-08 thru 9-24-08; SPD 13-2008, f. & cert. ef. 9-24-08;
SPD 15-2008, f. 12-26-08, cert. ef. 1-1-09; SPD 14-2013(Temp), f. & cert. ef.
7-1-13 thru 12-28-13; SPD 44-2013, f. 12-13-13, cert. ef. 12-15-13; APD 19-2015(Temp),
f. & cert. ef. 9-21-15 thru 3-18-16

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