Or. Admin. R. 411-032-0020 - Eligibility and Determination of Authorized Services

(1) Eligibility:
(a) In order to qualify for services from an area agency or service provider, each eligible individual must:
(A) Be 60 years old or older; or be under 60 years of age and be diagnosed as having Alzheimer's Disease or a related disorder;
(B) Not be receiving financial assistance or Medicaid, except Food Stamps, Qualified Medicare Beneficiary or Supplemental Low Income Medicare Beneficiary Programs; and
(C) Meet the requirements of the Long-Term Care Services Priority Rule, OAR 411, division 015.
(b) Eligibility determination will be required before any individual may receive services from an area agency or service provider. The documentation required by OAR 411-032-0015(1)(d) must be obtained before an individual under the age of 60 may be determined to be eligible.
(c) Eligibility determination will be the responsibility of the area agency. In those instances when eligibility determination is performed by an agency other than the area agency, the area agency will have in place a system for evaluating the eligibility determination process, including an independent review by the area agency of a representative sample of cases.
(d) Any person residing in a nursing facility, assisted living facility, residential care facility, or adult foster care setting will not be eligible for authorized services. This will not restrict the ability to move an eligible individual from such institutions to their home to receive services, when judged more appropriate, based on medical, financial, physical, functional, and social considerations.
(e) Any person residing in a living setting that offers any services authorized under OAR 411-032-0010 will be limited to receiving OPI services that are not available in that setting.
(f) The Department will determine the factors that constitute an individual being at risk of institutionalization. These factors are currently defined in the Long-Term Care Services Priority Rules, OAR chapter 411, division 015. These factors will be utilized by each area agency and service provider.
(g) Applicants will receive written notification of eligibility determination.
(2) Determination of Services:
(a) Determination of services will rest with the area agency. In those instances when determination of services is performed by an agency other than the area agency, the area agency will have in place a system for evaluating the determination of service process, including an independent review by the area agency of a representative sample of cases.
(b) The determination of services will be based on each individual's financial, physical, functional, medical, and social need for such services and in accordance with OAR chapter 411 division 015.
(c) Determination of services provided under Oregon Project Independence will be limited to the authorized services allowed by these rules.
(d) The determination of services will be made:
(A) After eligibility determination; and
(B) At regular intervals but not less than once every twelve months.
(e) Individuals will receive written notification of determination of services:
(A) Notice will include the maximum monthly hours of service authorized, the hourly and maximum monthly fee, the service rate, and provider contact information.
(B) Written service notification will be provided to the individual upon initial determination of services, at annual reassessment and when there are changes to the determination of services.
(3) Priority of Services:
(a) Area Agencies on Aging may establish local priorities for service authorization but will not conflict with this rule. In event of a grievance, this rule will take precedence over local priorities.
(b) Priority for authorized services will be:
(A) Maintaining eligible individuals already receiving authorized service as long as their condition indicates the service is needed.
(B) Individuals who will immediately be placed in an institution if needed authorized services are not provided and meet the Long-Term Care Services Priority Rules, OAR chapter 411, division 015.
(C) Individuals who are probably to be placed in an institution if needed authorized services are not provided.
(4) Appeals: Persons for whom services are denied, disallowed, or reduced through eligibility determination or service determination will be entitled to request review of the decision through the Area Agency on Aging grievance review procedure, set forth in agency policy.
(a) Individuals will continue to receive services until the disposition of the local agency grievance review.
(b) The Area Agency will provide the applicant with written notification of the grievance review determination decision.
(c) Applicants that disagree with the results of the Area Agency grievance review have a right to an Administrative Review with the Department of Human Services, Seniors and People with Disabilities Division, pursuant to ORS Chapter 183. This information will be provided to the applicant in a written notification at the time of the grievance review decision.
(d) Applicants requesting an Administrative Review from the Department will not be eligible for continued services through Oregon Project Independence.
(e) All persons, including those who may have previously been terminated from Oregon Project Independence, have the right to apply for OPI services at any time.

Notes

Or. Admin. R. 411-032-0020
SSD 11-1984, f. 11-30-84, ef. 12-1-84; SSD 12-1988, f. & cert. ef. 12-2-89; SSD 19-1989(Temp), f. 12-29-89, cert. ef. 1-1-90; SSD 5-1990, f. & cert. ef. 2-1-90; SSD 11-1993, f. 12-30-93, cert. ef. 1-1-94; SSD 3-1997, f. 11-28-97, cert. ef. 12-1-97; SDSD 7-1999, f. 6-30-99, cert. ef. 7-1-99; SDSD 9-2002(Temp), f. & cert. ef. 11-1-02 thru 4-29-03; SPD 11-2003, f. & cert. ef. 5-2-03; SPD 18-2004, f. & cert. ef. 5-28-04; SPD 29-2006, f. 10-23-06, cert. ef. 11-1-06

Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 410.430 & 410.450

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