Or. Admin. R. 411-027-0020 - Payment Limitations in Home and Community-Based Services
(1) PAYMENT FOR
SERVICES.
(a) Service payments under these
rules are limited to services provided under Oregon's Medicaid State Plan K
Option for individuals served through the Department's Aging and People with
Disabilities program area.
(b) Home
and community-based services include, but are not limited to:
(A) In-home services (consumer-employed
providers and contracted in-home care agencies).
(B) Residential care facility
services.
(C) Assisted living
facility services.
(D) Adult foster
home services.
(E) Specialized
living services.
(F) Adult day
services.
(G) Home-delivered
meals.
(2)
PAYMENT BASIS.
(a) Unless otherwise specified,
service payment is based upon an individual's assessed need for services as
documented in CA/PS.
(b) Payments
for home and community-based services are not intended to replace the resources
available to an individual from the individual's natural support system. The
Department may authorize paid services only to the extent necessary to
supplement potential or existing resources within an individual's natural
supports system.
(c) An individual
with excess income must contribute to the cost of services pursuant to OAR
461-160-0610 and OAR 461-160-0620.
(d) Service plans are based upon less costly
means of providing adequate services consistent with consumer's assessed need
and choice.
(e) An individual's
progress is monitored by Department or AAA local office staff. When a change
occurs in the individual's service needs that may warrant a change in the
service payment rate, staff must update the service plan.
(3) SERVICE PAYMENTS. All service payments
must be prior authorized by the Department or AAA local office staff.
(a) Department and AAA case managers
authorize service payments from the rate schedule based on an individual's
service program and assessed need for services documented in CA/PS.
(b) Any rate that differs from the rate
schedule must be pre-authorized by the Central Office.
(4) RATE SCHEDULE. Services are paid at the
rate in the Rate Schedule at the time of the service. The rate schedule must be
updated:
(a) When there is an increase in a
rate on the schedule; or
(b) Thirty
(30) days prior to when any rate is reduced.
(5) SPOUSAL SERVICES. The Department does not
make direct payments to a spouse for providing community-based services except
for in-home services as described in OAR chapter 411, division 030.
(6) PAYMENTS FOR ADULT DAY SERVICES.
(a) Payments to any Medicaid-contracted adult
day services program, as described in OAR chapter 411, division 066, are
authorized by Department or AAA local office staff and made in accordance with
the rate schedule.
(b) Adult day
services may be authorized as part of an overall plan of services for
service-eligible individuals and may be used in combination with other
community-based services if adult day services are the appropriate resource to
meet an identified need.
(c)
Department, or AAA local office staff, may authorize adult day services for
payment as a single service or in combination with other home and
community-based services. Adult day services are not authorized or paid for if
another provider has been authorized payment for the same service. Payments
authorized for adult day services are included in computing the total cost of
services.
(d) The Department pays
for a half day of adult day services when four or less hours of services are
provided, and pays for a full day of adult day services when more than four,
but less than 24 hours are provided.
(7) PAYMENT FOR HOME DELIVERED MEALS.
(a) Payments to any Medicaid-contracted home
delivered meals provider as described in OAR chapter 411, division 040 are
authorized by Department or AAA local office staff and made in accordance with
the rate schedule.
(b) Medicaid
home-delivered meals may be authorized as part of an overall plan of services
for service-eligible individuals and may be used in combination with other
in-home services if meals are the appropriate resource to meet an identified
need.
(8) PAYMENTS TO
ASSISTED LIVING FACILITIES. Payments to any Medicaid-contracted assisted living
facility (ALF) as defined in OAR 411-054-0005 are authorized by Department or
AAA local office staff and made in accordance with the rate schedule.
(a) The monthly service payment for an
individual receiving services in an ALF is based on the individual's degree of
impairment in each of the six activities of daily living as determined by CA/PS
and the payment levels described in paragraph (c) of this subsection. The
individual's initial service plan must be developed prior to admission to the
ALF and must be revised if needed within 30 days. The individual's service plan
must be reviewed and updated at least quarterly or more often as needed as
described in OAR 411-054-0034.
(b)
Activities of daily living are weighted for purposes of determining the monthly
service payment as follows:
(A) Critical
activities of daily living include elimination, eating, and cognition and
behavior.
(B) Less critical
activities of daily living include mobility, bathing, personal hygiene,
dressing and grooming.
(C) Other
essential factors considered are medical problems, structured living, medical
management, and other needs.
(c) Payment (Impairment) Levels.
(A) Level 1 -- Service priority level 1-13
eligible individuals are qualified for Level 1 or greater.
(B) Level 1 -- Service priority level 14-17,
but would require institutionalization without supports within 30 days if
authorized by Central Office.
(C)
Level 2 -- Individual requires assistance in cognition and elimination,
mobility, or eating.
(D) Level 3 --
Individual requires assistance in four to six activities of daily living or
requires assistance in elimination, eating, and cognition.
(E) Level 4 -- Individual is full assist in
one or two activities of daily living or requires assistance in four to six
activities of daily living plus assistance in cognition.
(F) Level 5 -- Individual is full assist in
three to six activities of daily living or full assist in cognition and one or
two other activities of daily living.
(d) The reimbursement rate for Department
individuals receiving Medicaid services shall not be more than the rates
charged by private paying individuals receiving the same type and quality of
services.
Notes
Statutory/Other Authority: ORS 410.070
Statutes/Other Implemented: ORS 410.070
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