The Department may authorize three
different types of special payment contract arrangements.
(a) Supplemented Program Contract. A
supplemented program contract pays a rate in excess of the rate schedule to
providers in return for additional services delivered to target populations.
(b) Consistent Revenue Contract. A
consistent revenue contract allows a payment rate based on average facility
case mix. The contracted rate is in the range allowed by the rate schedule and
is based on individual needs.
Specific Needs Setting Contract. A specific needs setting contract pays a rate
in excess of the rate schedule to providers who care for a group of individuals
all of whose service needs exceed the service needs encompassed in the base
payment and all add-ons.
SUPPLEMENTED PROGRAM CONTRACTS.
The Department may authorize a service
payment rate not included in the rate schedule for Residential Care Facilities,
Assisted Living Facilities and Adult Foster Homes providing additional services
to a targeted population, pursuant to a written contract with the Department.
To qualify, the facility must demonstrate to the Department that:
(A) There is a documented need for additional
services to the target population.
(B) The administrative and care staff have
sufficient program knowledge and skills to achieve program goals and provide
the additional services.
facility provides substantial additional services beyond those covered under
the rate schedule.
(D) There is a
comprehensive ongoing staff training program targeted to the population's
(E) The facility has made
any modifications necessary to provide the additional services.
The Medicaid individuals served in the
facility demonstrate increasing need for assistance with activities of daily
living and cognitive abilities due to Alzheimer's Disease or other dementia.
(i) "Alzheimer's Disease" means a chronic,
progressive disease of unknown cause that attacks brain cells or tissues.
(ii) "Dementia" means a clinical
syndrome characterized by a decline in mental function of long duration in an
alert individual. Symptoms of dementia include memory loss and the loss or
diminution of other cognitive abilities such as learning ability, judgment,
comprehension, attention and orientation to time and place and to oneself.
The facility has
provided the additional service for at least six months prior to the date on
which the supplemented program contract takes effect. Additionally, the
Department may approve supplemented program contracts to be effective prior to
the date on which the facility has provided the additional service for six
months based on:
(i) The Department
experience of provider ability to provide the additional service;
(ii) The recommendation of the Department and
AAA local office staff; or
Unmet community need for the additional services to be offered under the
facility may identify, at the time of application for the supplemented program
contract, the additional costs the facility incurs to deliver the additional
services. The facility shall include, at a minimum, the additional staffing and
training costs it incurs as a result of delivery of the additional services.
(b) The Department must
evaluate the information submitted by the facility, and may authorize a
contracted payment amount.
contract may be renewed at the appropriate payment rate on an annual basis for
a facility that continues to meet the criteria stated in section (1)(a) of this
(A) At the time of the request for
renewal, or at any other time the Department requests, the facility shall
provide the Department with information on actual costs incurred in delivery of
the additional services. Information provided by the facility shall be in the
format prescribed by the Department and shall, at a minimum, include the costs
of staffing the additional services and of training for direct care staff.
(B) The Department must evaluate
the information submitted by the facility, and may re-authorize a contracted
supplemented program contract rate may be increased only if the Legislative
Assembly authorizes the Department to do so and appropriates the funds needed
to pay the increase.
CONSISTENT REVENUE CONTRACTS. The
Department may authorize a service payment rate not included in the rate
schedule for Residential Care Facilities, Assisted Living Facilities and Adult
Foster Homes that request a consistent revenue rate pursuant to a written
contract with the Department.
(a) In a
consistent revenue contract, the Department establishes a uniform service
payment rate for all individuals. The uniform service payment rate is
equivalent to the average service payment rate the Department pays under the
rate schedule. In no case shall the consistent revenue contract payment exceed
the average amount the Department pays to the facility under the rate schedule.
A provider must request a
consistent revenue contract in writing. The request must include the suggested
payment amount and justify the calculation of that amount by attaching copies
of the most recent three full calendar months Provider Individual Summary Form.
(A) If a request for a consistent revenue
contract and the required justification are received by the Department on or
before the 15th of the month, the consistent revenue contract payment amount is
effective for payment for services rendered on or after the first day of the
month immediately following receipt of the request.
(B) If a request for a consistent revenue
contract and the required justification are received by the Department after
the 15th of the month, the consistent revenue contract payment amount is
effective for payment for services rendered on or after the first day of the
second month following receipt of the request.
(c) A consistent revenue contract may be
terminated by the facility by providing 30 days written notice to the
Department. If a consistent revenue contract is terminated, service payments
for individuals are made in accordance with the rate schedule.
(d) The Department may terminate a consistent
revenue contract by providing 30 days written notice to the facility. If a
consistent revenue contract is terminated, service payments for individuals are
made in accordance with the rate schedule.
Payment rates under consistent revenue
contracts may be adjusted due to changes in facility case mix.
(A) The Department must review facility case
mix annually at contract renewal. The determination of average facility case
mix is based on the average service payment level to which the Department has
assigned individuals over the three calendar months that precede the
section (3)(e)(A) of this rule, in the first year during which a facility is
paid under a consistent revenue contract, the facility may request that the
consistent revenue contract payment be recalculated after six months. The
request must include the recommended payment amount and justification of that
payment rate amounts paid under a consistent revenue contract are increased as
a result of legislatively approved increases at the same time and in the same
way as are other facilities of the same licensure.
SPECIFIC NEEDS SETTING CONTRACTS.
(a) Specific needs settings are found in
Adult Foster Homes, Residential Care Facilities and Assisted Living Facilities.
These settings provide community-based care services for individuals whose
needs are not met by the rate schedule.
Determination of facility eligibility for
a specific needs setting contract is at the discretion of the Department. In
making its determination, the Department shall consider:
(A) The needs of the individuals being
availability of other community long-term care options to meet individual
(C) The proportion of
facility individuals demonstrating the specific needs setting care need and
other factors as the Department may determine.
(c) The provider shall submit information to
the Department in the form and at the time requested in order to determine the
Medicaid rate to be paid.
total rate for specific needs setting contracts shall be approved by the
Department. The approved rate is a single rate paid for all Title XIX
individuals with the specific needs setting care need that live in the eligible
Or. Admin. R.
SDSD 10-2001, f. 12-27-01,
cert. ef. 1-1-02; SPD 7-2008, f. 5-29-08, cert. ef. 6-1-08; SPD 7-2008, f.
5-29-08, cert. ef. 6-1-08; APD 33-2014, f. & cert. ef.
Stat. Auth.: ORS
Stats. Implemented: ORS