Or. Admin. R. 411-027-0050 - Exceptions to Payment Limitations in Home and Community-Based Services

(1) Service payment exceptions may only be granted if the Department determines:

(a) The individual has service needs, documented in the service plan, that warrant a service payment exception; and

(b) The provider actually provides the exceptional service.

(2) Service payment exceptions shall be based on the additional hours of services required to meet the individual's assessed and verified ADL and IADL service needs. Exceptional hours are not allowed based solely on choice of the individual. The Department and AAA local office staff must monitor the individual service needs and recommend adjustments to the plan when appropriate.

(3) Service payment exceptions in Adult Foster Homes and Residential Care Facilities may be authorized only for individual service needs that are not paid for by the base rate or any of the three available add-on payments.

(4) Additional hours for Adult Foster Homes and Residential Care Facilities are paid at the hourly rate in the rate schedule. The Department does not authorize additional payment exceptions for building, utilities, food, or regular maintenance.

(5) No service rate exceptions are allowed in Assisted Living Facilities.

(6) Exceptions above the maximum monthly hours of service in OAR 411-030-0070 for in-home services, may only be granted when it is determined the placement is the most appropriate for the resident, special services are necessary to meet individual needs, not preference, and a provider has the capability to meet those needs.

(7) All individual exceptions to the assessed service need determination in Adult Foster Homes, Residential Care Facilities, or in-home settings, and renewals of exceptions, must be pre-authorized by the Department's APD Central Office.

(a) A consumer or consumer representative may request an exception by requesting the rate or hours exception through their case manager. A case manager may also determine that an exception is needed and initiate the process.

(b) The Department and AAA local office staff shall review and approve requests for payment exception before they are transmitted to the Department's APD Central Office.

(c) Locally approved requests for payment exception must be sent to the Department's APD Central Office. The request must include:

(A) A statement of individual needs that exceed the assessed rate or the maximum monthly hours of services; and

(B) A statement of how the individual's needs are met and the cost involved in meeting the individual's needs.

(d) The Department's APD Central Office must review and approve exception requests and transmit the decision and effective date to the Department and AAA local office staff. Approval will only be granted if the exception meets an unmet need and is reasonable to meet that unmet need.

(e) The Department or the Department's Central Office may deny exception requests. A notice of planned action is required if the individual or their representative requested the exception.

(f) Rate exceptions expire one year from the effective date or on the date determined by the Department's Central Office.

Notes

Or. Admin. R. 411-027-0050

SDSD 3-1998, f. 2-27-98, cert. ef. 3-1-98; SDSD 4-1998, f. 6-25-98, cert. ef. 7-1-98; SDSD 10-2001, f. 12-27-01, cert. ef. 1-1-02; SPD 7-2008, f. 5-29-08, cert. ef. 6-1-08; APD 33-2014, f. & cert. ef. 9-2-14; APD 20-2017, temporary amend filed 09/29/2017, effective 10/01/2017 through 03/29/2018; APD 9-2018, amend filed 03/28/2018, effective 3/29/2018

Statutory/Other Authority: ORS 410.070

Statutes/Other Implemented: ORS 410.070